APPENDIX III - General Declation Format.pdf
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- Solicitation number
- 1331L525R13OS0001
About this file
This is a standard declaration form template (Appendix III) used by the U.S. Department of Commerce for EEO investigation complaints. The template provides a structured format for witnesses to provide statements regarding EEO complaints, requiring personal identification details (name, grade, title, organization unit) and declarations made pursuant to 28 U.S.C. § 1746.
The form requires double-spaced witness statements addressing each investigated claim, even if the witness has no knowledge of specific allegations. It includes provisions for page numbering, initials on each page except the last, and concludes with a declaration under penalty of perjury that the statement is true, correct and complete. The form explicitly states that provided information is not confidential and may be shared with interested parties. This is a template document that does not contain specific complaint information or requirements.
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Text version
Appendix III.
GENERAL DECLARATION FORMAT
<COMPLAINT>
v.
Complaint Number:__________
U.S. Department of Commerce
I, <Name>, <Grade>, <Title>, <Organization Unit>, pursuant to 28 U.S.C. § 1746, hereby declare:
[Insert the body of the witness statement, DOUBLE SPACE to facilitate reading and handwritten corrections. Include a response to each claim accepted for investigation, even if the response is that the witness has no knowledge or information concerning a specific allegation.]
Page ____ of ____pages.
Initials:
[LAST PAGE]
I have read the above statement consisting of ____ pages. I declare under the penalties of perjury that my statement is true, correct and complete to the best of my knowledge and belief. I understand that the information I have given is not to be considered confidential and that it may be shown to the interested parties.
_____________________ Executed on:_______________ <Name>
Page ____ of ____ Pages [No initials on the last, signed page.]
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