Get Form Ssa-437-bk 2023-2025

The Form SSA-437-BK is designed to assist users in filing a complaint of discrimination regarding programs or activities conducted by the Social Security Administration. This guide will provide step-by-step instructions on how to complete this form online effectively.

Follow the steps to complete your Civil Rights Complaint Form online.

1. Click the ‘Get Form’ button to access the SSA-437-BK form and open it in your chosen online editor.
2. In the first section, provide the name and address of the person(s) who allegedly experienced discrimination. Include their city, state, ZIP, and daytime phone number.
3. If you are completing the form on behalf of someone else, fill in your name and contact information in the next section.
4. Explain your relationship to the person identified in the first section. Clarify any relevant connections you have.
5. Provide detailed information regarding why you believe discrimination occurred, referencing SSA's policies regarding discrimination.
6. Document the dates when you believe the alleged discrimination took place.
7. If the incident occurred more than 180 days ago, explain why you waited to file your complaint and request a waiver if needed.
8. Describe the specific action taken by SSA that you believe was discriminatory and provide details about any individuals involved in the incident.
9. List any witnesses who may have information relevant to your complaint, including their names and contact information.
10. If you have previously communicated with any SSA officials regarding the discrimination, document the names, dates, and the nature of those discussions.
11. Specify the remedy or accommodation you are seeking as a result of the alleged discrimination.
12. Indicate whether you or the person you are representing has filed a complaint with any other agency. If so, provide details.
13. Answer how you learned about your ability to file this complaint.
14. Finally, ensure that both you and the person who has been discriminated against sign and date the form before submission.
15. Once completed, you can save your changes, download the form, print it, or share it as necessary.

Take action now by filling out the Form SSA-437-BK online to ensure your complaint is heard.