Irs Complaint Form (Page 3 of 3) in pdf

Irs Complaint Form Page 3

10. Do you have any other information that you think is relevant to our investigation of

your allegations?

11. What remedy are you seeking for the alleged discrimination?

Please sign and date the Complaint Form below.

(

Signature)

(Date)

We will also need your consent to disclose your name, if necessary, in the course of the

investigation. Please sign the attached Consent Form and mail both the completed

Complaint Form and Consent Form, to the following address:

Operations Director, Civil Rights Division

Internal Revenue Service

1111 Constitution

Avenue, NW Room 2413

Washington, DC 20224

How did you learn about the IRS Civil Rights Division?

IRS Website/Internet Search

Family/Friend/Associate

Religious/Community Org

Lawyer/Legal Organization

Employer

Fed/State/Local Gov

Healthcare Provider/Health Plan

Conference/OCR Brochure

Other

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that the

requested information is being collected to ensure that we receive all the information that is needed to

process your complaint upon acceptance. The primary purpose of this form is to obtain information

pertaining to your civil rights complaint. Our legal authority to request this information is the Department

of Justice, Investigation Procedures Manual. The CRD will not disclose the name or other identifying

information about the complaining individual unless the disclosure is necessary for investigation or

enforcement purposes and we have obtained a signed consent/release from that individual, OR unless

disclosure of such information is both necessary and permitted absent consent pursuant to the provisions

of the Privacy Act of 1974 (5 U.S.C. §552a), the Freedom of Information Act (5 U.S.C. §552), and/or

other federal law.

Irs Complaint Form Page 3