Form 10 Statement Concerning Discrimination
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Form 10 Statement Concerning Discrimination Form. This is a Official Federal Forms form and can be use in US Court Of Appeals For The Federal Circuit.
Tags: Form 10 Statement Concerning Discrimination, 10, Official Federal Forms US Court Of Appeals For The Federal Circuit,
ÚÑÎÓ ïðò Í¬¿¬»³»²¬ Ý±²½»®²·²¹ Ü·-½®·³·²¿¬·±²
ËÒ×ÌÛÜ ÍÌßÌÛÍ ÝÑËÎÌ ÑÚ ßÐÐÛßÔÍ ÚÑÎ ÌØÛ ÚÛÜÛÎßÔ Ý×ÎÝË×Ì
____________________________ v. ____________________________
PETITIONER’S FED. CIR. R. 15(c) STATEMENT CONCERNING DISCRIMINATION
Please complete sections A, B, and C.
Check the statements in section A 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
_____ (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
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 so, identify any case. _________________________________________________________
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 so, identify any case ________________________________________________________
Mail this form with the petition for review or within 14 days of the date of docketing of the
petition for review to:
Clerk, United States Court of Appeals for the Federal Circuit
717 Madison Place, NW
Washington, DC 20439
May 1, 2006 Edition
American LegalNet, Inc.