Form TD F 62-03.6 TD F 62-03.6 Agreement to Extend Counseling

Privacy Act Statement
AUTHORITY: 29 U.S.C. § 206(d); 29 U.S.C. § 791; 42 U.S.C. § 2000e; 42 U.S.C. § 2000ff-(2);
29 U.S.C. § 633a; 5 U.S.C. § 1303-1304; 5 CFR § 5.2-5.3; 29 CFR § 1614.105, .107; Executive
Order 11478, as amended; and Executive Order 13152 and Management Directive 110 (August
2015).
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose to record a
pre-complaint allegation of employment discrimination with the Department of the Treasury on
the grounds of race, color, religion, sex (including pregnancy), national origin, age, disability,
protected genetic information, parental status, or reprisal. An employee or applicant must
participate in pre-complaint EEO counseling to informally resolve the allegation(s) per §
1614.105, prior to filing a formal EEO complaint of discrimination. Information provided on this
form will be used by the aggrieved to extend the EEO counseling process for not more than 60
calendar days, not to exceed a total of 90 days. The information captured on this form will be
used by the Department of the Treasury to record the election of the aggrieved to extend EEO
counseling beyond the 30-day period allowed for EEO counseling.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under
5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using this information
as necessary and authorized by the routine uses published in Treasury .013--Department of the
Treasury Civil Rights Complaints and Compliance Review Files – 81 FR 78266 (Nov. 7, 2016).
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction
Act of 1995, the Department of the Treasury may not conduct or sponsor, and the respondent is
not required to respond to this collection of information unless it displays a valid OMB Control
Number. The valid OMB Control Number for this information collection is 1505-0262. The
collection of this information is voluntary. However, the information is necessary to determine if
your complaint of employment discrimination is acceptable for further processing in accordance
with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing the
form. Send comments regarding this burden estimate or any other aspects of this collection,
including suggestions for reducing this burden, to Department of the Treasury, Office of Civil
Rights and EEO, 1500 Pennsylvania Avenue, N.W., Washington, DC 20220.
TD F 62-03.6
Revised 04/2025

S p a c e le f t
b la n k f o r
b u re a u ’s s e a l

OMB No. 1505-0262
Expiration Date: 06/30/20XX

Department of the Treasury
S p a c e le f t b la nk f o r b u re a u ’s
nam e
Name of the Counselee: ____________________________
Pre-Complaint Number: ____________________________

Agreement to Extend Counseling
In accordance with §1614.105(e) of the Equal Employment Opportunity Commission (EEOC)
Regulations (29 CFR part 1614), the undersigned agrees to postpone the final interview on
the matter(s) upon which EEO counseling was first sought. It is understood that
counseling may extend for not more than 60 days beyond the end of the 30-day period
allowed for counseling. If counseling is completed prior to the end of the period stated
above, and the matter(s) remains unresolved, a “Notice of Right To File a Formal
Discrimination Complaint Under 29 CFR Part 1614” will be provided.
___________________________________
Date EEO Counseling was First Sought
_________________________________
th
30 Calendar Day

_____________________________________
th
90 Calendar Day

______________________________________________________
______________________________________________________
Signature of Counselee

________________________
Date

_______________________________________________________
Signature of EEO Counselor

________________________
Date

_____________________________________________________
Signature of Counselee's Representative

________________________
Date

TD F 62-03.6
Revised 04/2025