FORM 10. Statement Concerning Discrimination Form 10 Rev. 03/16 UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT v. No. PETITIONER'S FED. CIR. R. 15(c) STATEMENT CONCERNING DISCRIMINATION Please complete sections A, B, and C. Section A: Check the statements below that apply to your case. Usually, it is one statement, but it may be more. Do not alter or add to any of the statements. (1) No claim of discrimination by reason of race, sex, age, national origin, or handicapped condition has been or will be made in this case. (2) Any claim of discrimination by reason of race, sex, age, national origin, or handicapped condition raised before and decided by the Merit Systems Protection Board or arbitrator has been abandoned or will not be raised or continued in this or any other court. (3) The petition seeks review only of the Board's or arbitrator's dismissal of the case for lack of jurisdiction or for untimeliness. (4) The case involves an application to the Office of Personnel Management for benefits. (5) The case was transferred to this court from a district court and I continue to contest the transfer. Section B: Answer the following: Have you filed a discrimination case in a United States district court from the Board's or arbitrator's decision? Yes No If yes, identify any case. Section C: Answer the following: Have you filed a discrimination case in the Equal Employment Opportunity Commission from the Board's or arbitrator's decision? Yes No If yes, identify any case. Date Petitioner's signature Mail this form with the petition for review or within 14 days of the date of docketing of the petition for review to: Clerk of Court United States Court of Appeals for the Federal Circuit 717 Madison Place, NW Washington, DC 20439 cc: American LegalNet, Inc. www.FormsWorkFlow.com