Fill and Sign the Nv Division of Mineralsaffidavit of Annual Assessment Work Form 160730

U.S. Department of Justice Office of Special Counsel Charge Form for Unfair Immigration-Related Employment Practices Instructions Instructions This charge form is to be used only to file a charge alleging an unfair immigration-related employment practice in violation of 8 U.S.C. §1324b. This charge form must be filed with the Office of Special Counsel for Immigration Related Unfair Employment Practices. U.S. Department of Justice Civil Rights Division Office of Special C ounsel for Immigrati on Related Unfa ir Employment Pra ctices 950 Pennsylvan ia Avenue, N.W. Washington, D.C. 20530 On the form, “Injured Party” means a person who claims to have been adversely affected directly by an unfair immigration-related employment practice or, in the case of a charge filed by an officer of the Immigration and Naturalization Service or by a Charging Party other than the Injured Party, is alleged to be so affected. On the form, “Charging Party” means: (1) an individual who files a charge with the Special Counsel that alleges that he or she has been adversely affected directly by an unfair immigration-related employment practice; or (2) an individual or private organization who is authorized by an individual to file a charge with the Special Counsel that alleges that the individual has been adversely affected directly by an unfair immigration-rel ated employment practice; o r (3) an officer of the Immigratio n and Naturalizati on Service who files a charge with the Special Counsel that alleges that an unfair immigration-related practice has occurred. The “Charging Party” shou ld complete the charge for m in its entirety by typing, or neatly printing, th e information request ed. If a question is not applicable, it sh ould be left blank. This charge form must be delivered or mailed to the Office of Special Counsel within 180 days of the alleged discrimination. Questions concerning this charge form can be directed to the Office of Special Counsel by mail at the above address or by telephone at (202) 616-5594 or 1-800-255-7688 (toll free), TDD (202) 616-5525 or 1-800-237-2515 (toll free). 1. Charging Party Full Name: Telephone: ( ) Other Names Ever Used: Street Address: City : State: Zip Code: Injured Party (IF INJURED PARTY is same as CHARGING PARTY, write “same”) Full Name: Telephone: ( ) Other Names Ever Used: Street Address: City: State: Zip Code: 2. Individual, Business or Enitiy Which You Believe Has Committed Unfair Employment Practice: Full Name: Telephone: ( ) Street Address: City: State: Zip Code: Form OSC-1 Nov. 01 Formerly Form CRT-37 w hich is obsolete. 3. Individual, Bu siness or Entity H as (check one): ~ Less than 15 employees, but more than 3 employees. ~ 15 or more employees . ~ Unable to estimate number of employees. 4. Injured Party Has Suffered an Unfair Immigration-Related Employment Practices (check one or more) ~ National Origin Discrimination (with respect to the hiring, recruitment or referral, or discharging of the Injured Party) ~ Citizen ship St atus Dis crimin ation (wi th respec t to the h iring, r ecruitm ent or refer ral, or di schargi ng of the Inj ured Part y) ~ Retaliation for Asserting Rights Protected Under 8 U.S.C. §1324b ~ Document Abuse (The individual, business, or organization refused to accept a valid document or demanded more or different documents that are required for completing the INS Form I-9) 5. Injured Pa rty Is: ~ Citizen or National of the United States (if this box is marked continue on to #6) ~ Alien Authorized to Work in the United States (if this box is marked you must complete the rest of #5) If INJURED PARTY is an alien authorized to work in the United States: Alien Registration Number (s): Date of Birth: (day) (month) (year) If INJURED PARTY is an alien authorized to work in the United States: Injured Party (check one if applicable ): Injured Party (check one): ~ Is lawfully admitted for p ermanent resid ence ~ Has applied for naturalization date granted:_________________________ ~ Has status of a lien lawfully admit ted for temporary resi dence under 8 U.S.C. §1160(a), 8 U.S.C. §1161(a), or 8 U.S.C. §1255(a)(1) ~ Has not applied for naturalization Date of Application:______________________________________________ ~ Is admitted as refugee under 8 U.S.C. §1157 ~ Has been granted asylum under 8 U.S.C. §1158 ~ Is Otherwise Authorized to work 6. When did the unfair practice occur: (date)________________________________________________________________ 7. Where did the unfair practice occur: (Place)_______________________________________________________________ 8. Has a charge based on this set of facts been filed with the Equal Employment Opportunity Commission, or other governmental agency? ~ Yes If yes, which office? ________________________________________________________________________________________ ~ No Address:__________________________________________________________________________________________________ City: __________________________________State:______________________Zip Code:________________________________ Date Filed:_________________________________File No. (if known):_______________________________________________ 9. Describe the Unfair Employment Practice (use additional sheets if necessary) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 10. Affirmation and Signature of C harging Party (a) If this charge is being fi led by the Inj ured Part y: As a person alleging that I have been injured by an unfair immigration-related employment practice, I understand that the Office of Special Counsel may find it necessary to reveal my identity and other information during the cond uct of the investigation of my charge, during any hearing or oth er proceeding as result of my charge, or in limited circumstances in response to inquiries under the Freedom of information Act. I give my consent. I affirm that, to the best of my knowledge, the in formation provi ded on this for m is true. _________________________________________________________________ (Signature of Injured Party) (b) ______________________________________ (Date) If this charge is being fi led by an a uthoriz ed represen tative of the Injure d Party: I affirm that, to t he best of my knowledge, the informati on provided on t his form is tru e and that I am au thorized to file th is charge on beh alf of the Injured Party. I understand that the Office of Special Counsel may find it n ecessary to reveal my identity during the conduct of the investigation of thi s charge, during a hearing or other proceeding as a result of this charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent. ________________________________________________________________ (Signature of Authorized Representative) (c) ______________________________________ (Date) If this charge is being filed by an INS officer: I affirm that, to the best of my knowledge, the information provided on this form is true. I understan d that the Office of Special Counsel may find it necessary to reveal my identit y during the con duct of the in vestigation of t his charge, d uring a heari ng or other proceed ing as a result of this charge, o r in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent. ________________________________________________________________ (Signature of INS Officer) _______________________________________ (Date) IMPORTANT NOTICE CONCERNING IMMIGRATION-RELATED UNFAIR EMPLOYMENT PRACTICES U.S. immigration law prohibits discrimination on the basis of national origin with respect to the hiring, firing, or recruitment or referral for a fee of: ! Citizens or nationals of the United States; and ! Aliens authorized to work in the United States It also prohibits discrimination on the basis of citizenship status with respect to the hiring, firing, or recruitment or referral for a fee of: ! Citizens or nationals of the United States; and ! Protected Aliens (permanent residents, temporary residents, refugees, and asylees) This law is enforced by an independent Office of Special Counsel in the Department of Justice. Because the law requires that complaints must be filed within 180 days from the date of the act of discrimination, if you believe that you have been discriminated against, you should immediately notify the Office Special Counsel. You may call this number toll-free: 1-800-255-7688 (202-616-5594 in Washington, D.C.) TDD: 1-800-237-2515 (202-616-5525 in Washington, D.C.) Or you may write to: U.S. Department of Justice Civil Rights Division Office of Special Counsel for Immigration Related Unfair Employment Practices 950 Pennsy lvania Avenue, N.W. Washington, D.C. 20530 __________________________________________________________________________________________________________________ PRIVACY ACT STATEMENT The authority for requesting this information from you is contained in 8 U.S.C. Section 1324b. The information that you provide will be used principally for investig ating and processing your c harge of prohibited discri mination; however, the information may al so be used for other legitimate purposes, as detailed in this Office’s notice published in the Federal Register describing the routine uses of the information obtained by the Office. Your failure to provide the information requested on this form could lead to your charge being dismissed or not being accepted. Knowingly making false statements on this form is punishable under 18 U.S.C. Section 1001.