Discrimination Complaint Form

SSA collects information on Form SSA-437-BK to investigate and formally resolve complaints of discrimination based on disability, race, color, national origin (including limited English language proficiency), sex, sexual orientation, age, religion, or retaliation for having participated in a proceeding under this administrative complaint process in connection with an SSA program or activity. Individuals who believe SSA discriminated against them on any of the above bases may file a written complaint of discrimination. SSA uses the information to: (1) identify the complaint; (2) identify the alleged discriminatory act; (3) establish the date of such alleged action; (4) establish the identity of any individual(s) with information about the alleged discrimination; and (5) establish other relevant information that would assist in the investigation and resolution of the complaint. This form has no bearing on any right to pursue, obtain, or keep Social Security benefits. The civil rights complaint process and the use of this form is entirely voluntary. SSA will also accept a letter or other written communication in the alternative to this form. Individuals do not need to use this form or submit a letter or otherwise exhaust administrative remedies before filing a discrimination lawsuit in U.S. District Court. There is no survey associated with this form. Respondents can submit the form by mail or email. Respondents may fill out the form with help from a person they choose, such as a relative, friend, or lawyer. They will not need information from others to complete it. SSA uses its existing Microsoft Office software to collect and work with incoming complaints. The Respondents are individuals who believe SSA, or SSA employees, contractors, or agents, discriminated against them in connection with programs or activities conducted by SSA.

The latest form for Discrimination Complaint Form expires 2026-04-30 and can be found here.