Get Form Ssa-437-bk 2023-2025

The Form SSA-437-BK is designed to help you file a civil rights discrimination complaint regarding programs administered by the Social Security Administration. This guide provides detailed, step-by-step instructions to ensure that your form is completed accurately and efficiently when submitting online.

Follow the steps to fill out the Form SSA-437-BK online:

1. Click the ‘Get Form’ button to access the form and open it in your browser.
2. Begin by entering the name, address, and contact details of the person who allegedly experienced discrimination in the designated fields.
3. If you are completing the form on behalf of someone else, fill in your details in the section for the person completing the form, ensuring you provide your name, address, and contact information.
4. Explain your relationship to the person identified in Question 1 in the designated area to clarify your connection.
5. Provide a detailed account of why you believe discrimination occurred, focusing on the basis of discrimination as outlined by the SSA policy.
6. Indicate the date(s) when the alleged discrimination took place in the specified fields.
7. If the events occurred more than 180 days ago, explain your reason for the delay in filing the complaint, requesting a waiver if applicable.
8. Describe the actions by SSA that you believe were discriminatory, detailing any specific incidents, including names of individuals involved, their actions, and relevant contact information or dates of any communication with SSA.
9. List any witnesses who may have information about the discrimination, including their names, addresses, and phone numbers as appropriate.
10. If you have discussed the matter with any SSA officials, provide their names, office details, dates of the conversations, and a summary of what transpired.
11. State what action or remedy you are seeking from the SSA in response to your complaint, explaining what you hope to achieve.
12. Indicate if you have filed this complaint with another agency by selecting yes or no, and if yes, provide details about the other agencies involved and the date of filing.
13. Annotate how you learned about your option to file this complaint, giving any relevant sources or information you received.
14. Sign and date the form in the designated area to confirm that all information is accurate. If someone is representing the person allegedly discriminated against, ensure both signatures are included.

Now that you know how to fill out the Form SSA-437-BK online, complete your complaint without delay.