Claim Information Form

49 U.S.C., Section 5333(b) CLAIM INFORMATION
NOTE: This form is for general informational purposes only, and does not restrict the scope of the claim,
information, or remedy. Submission of this form does not indicate acceptance of a Section 5333(b) claim.
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Print or type in Blue or Black Ink
You may add additional pages, as necessary, include item number for reference.
Attachments should be marked accordingly with a document listing.
Please answer the following to the best of your knowledge

1. Claimant’s name & address:

2. Party responsible for Employee Protections:

________________________________

Company_______________________

________________________________

Chief Exec_______________________

________________________________

Address_________________________

________________________________

________________________________

telephone (____) ___________________

telephone (____) __________________

Email address: _____________________

Email address: ___________________

3. Claimant’s employer (if different from #2):
Company____________________________
Chief Exec___________________________
Address _____________________________
______________________________
telephone (____) ______________________
Email address: ________________________________

4. Claimant’s position with employer (job):_________________
employed from ______________

to

___________________

5. Date the employee was affected by a Federal project, ________________________
(or) date of violation(s) of the employee protections

________________________

_____________________________________________________________________
_____________________________________________________________________

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

49 U.S.C., Section 5333(b) CLAIM INFORMATION

6. Please state your complaint, and what happened. State how you have been
affected and how these effects resulted directly or indirectly, at least in part, from
Federal transit assistance. Also, state how the employee protections have been
violated, citing the particular protective arrangements provisions or the statute which
have been violated by the recipient (responsible party).
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_____________________________________________________________________
_____________________________________________________________________
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_____________________________________________________________________
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_____________________________________________________________________
7. If the claim alleges that an employee was affected by Federal transit assistance,
please identify the following:
Project No(s). ______________________ Date(s)___________________

Purpose of Project(s)_______________________________________________
________________________________________________________________

8. State the remedies you seek (such as: reinstatement, back pay, restoration of
seniority, negotiation of changes in employment conditions, etc.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

49 U.S.C., Section 5333(b) CLAIM INFORMATION
9. What is the basis (labor contract, protective arrangement, past practice, personnel
policy, etc.) of the rights and the protections you seek?
Please provide a copy of each document you cite.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

10.

Are you a member of a bargaining unit represented by a labor union?________
Are you non-member covered by a collective bargaining agreement? ________
If yes to either, please identify:
Bargaining Unit: _____________________________________
Union name: ________________________________________
Local No.:

________________________________________

Local President: ______________________________________
Address:

_________________________________________
_________________________________________

telephone no. (______) ________________________________

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

49 U.S.C., Section 5333(b) CLAIM INFORMATION
11. Describe any preliminary steps you or your representative may have already taken
to resolve your claim (such as a grievance filing, verbal, electronic, or documented
correspondence, filing of a formal complaint to your employer or the recipient of Federal
assistance, or arbitration of the dispute). Include the date(s) of any steps taken, to
include the name of the person and entity with whom the complaint was filed, and the
current status of the complaint (resolved, denied, under review or appeal, etc…).
Please provide a copy of any document you cite, including a copy of any formal
complaint, a copy of any response(s) to the complaint, and a copy of any written
procedure under which the complaint was filed (such as a union contract, employee
complaint procedure, or 13(c) complaint form).
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_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

49 U.S.C., Section 5333(b) CLAIM INFORMATION
12. Provide any additional information which may be helpful in considering your claim.
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13. I hereby certify that the information in this application for protections under 49
U.S.C., Section 5333(b) is true and complete to the best of my knowledge.

___________________________________
Claimant’s signature

______________________
Date

Enclosures (provide attachments of necessary records)

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

49 U.S.C., Section 5333(b) CLAIM INFORMATION

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

U.S. Department of Labor, OLMS, Division of Statutory Programs

2011

Denise Diminuco

Digitally signed by Denise Diminuco
DN: cn=Denise Diminuco, o=OLMS - Div. of
Statutory Programs, ou=US Department of
Labor, email=Diminuco.Denise@dol.gov, c=US
Date: 2012.03.08 08:45:14 -05'00'