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8c. NAME 8d. GRADE 8f. AGENCY 8g. SIGNATURE DA FORM 7279 SEP 2010 PREVIOUS EDITIONS ARE OBSOLETE. 8e. EQUAL OPPORTUNITY COMPLAINT FORM For use of this form see AR 600-20 the proponent agency is DCS G-1. PRIVACY ACT STATEMENT AUTHORITY Title 10 USC Section 3013 Secretary of the Army Army Regulation 600-20 Army Command Policy. PRINCIPAL PURPOSE To provide a means for filing complaint based on discrimination due to race color religion or national origin* ROUTINE USES None DISCLOSURE Voluntary However failure to provide all the requested information could lead to rejection of complaint for inadequate data* 1. NAME 2. RANK 3. UNIT 4. RACE/ETHNIC GROUP 5. GENDER 6. DATE YYYY/MM/DD PART I - COMPLAINT 7a* NATURE OF COMPLAINT. Give in as much detail as possible the basis for your complaint describe the incident/behavior s and date s of the occurrence s the names of parties involved witnesses and to whom it may have been previously reported plus any additional information that would be helpful in resolving your complaint* Attach additional sheets as needed* 7b. REQUESTED REMEDY. What do you think the final outcome should be 8a* AFFIDAVIT. have read or have had read to me I this statement which begins on this page page 1 and ends on page. I fully understand the contents of the entire statement made by me. The statement is true. I have initialed all corrections. I made the statement without threat of punishment and without coercion unlawful influence or unlawful inducement. Signature of Person Making Statement Subscribed and sworn to before me a person authorized by law to administer oaths this day of. at Typed/Printed Name of Person Administering Oath 8b. AGENCY RECEIVING COMPLAINT. I acknowledge receipt of this complaint from of name/rank unit on date. I understand I have 3 calendar days next drill period for reserve soldiers in which to refer this complaint to the appropriate commander of the complainant. DATE YYYY/MM/DD Page 1 of 2 APD PE v1. 00 9a* ACKNOWLEDGEMENT. submitted to me by name rank alternative agency on Reserve components in which to initiate an investigation into the complaint implement a plan to prevent reprisal complete the investigation and inform the complainant of the results of that investigation* All formal complaints will be reported within 72 hours to the first GCMCA in the chain of command. 9b. NAME 9c* GRADE 9e. ORGANIZATION 9f* SIGNATURE 9d. DATE PART II - RESULTS OF INVESTIGATION 10a* I name of commander your allegations. I reviewed the report of investigation into concur substantiated nonconcur with the findings of the investigating officer. I find that your allegations are 10c* DATE YYYY/MM/DD 10b. SIGNATURE OF COMMANDER PART III - ACTIONS TO RESOLVE COMPLAINT 11a* The command has done or will do the following actions to resolve this complaint and continue to prevent acts of reprisal 11b. ADVISEMENT TO COMPLAINANT You have the right to appeal these actions to resolve your complaint* You will have 7 days next weekend drill for Reserve components to submit your appeal in writing.

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