Step 1 of 8 - Address Update 12% CLAIM FORM JONES ET AL., V. CHOPRA ET AL. IMPORTANT: In order to receive a Discretionary Award in this Settlement, you must complete and sign this Claim Form, and it must be received by the Claims Administrator by April 1, 2024. You may submit your claim form in one of three ways: (1) complete and submit this electronic claim form, (2) upload a completed claim form HERE; or (3) mail the claim form to the address below. CFPB Claims Administrator c/o Atticus Administration PO Box 64053 Saint Paul, MN 55164 INSTRUCTIONS Please verify the accuracy of your Name and Address. If any of the information is incorrect or incomplete, provide the correct information below. Provide as much detail as necessary to fully answer the questions below, including dates. If you are guessing at names or spellings of names, please make that clear in your answer(s) and/or provide as much additional detail as possible to help identify the individual(s) (e.g., "my direct supervisor in 2014"). When identifying other individuals who worked at the Bureau, include their title and whether they worked in management. If you do not know their title, describe their relationship to you (e.g., "my supervisor," "my coworker," "my team lead," or "a manager"). If you are uncertain of dates of incidents described in your responses, please provide as much detail as possible to help identify the time period (e.g., "late fall 2015," "2014 between Christmas and New Year," "shortly after the 2016 Presidential election," etc.). In order to receive an award for emotional distress, you must complete Section L regarding emotional distress. You may but are not required to submit additional documentation regarding your emotional distress, such as medical records. If you wish for the Neutral to consider losses that you have suffered after your employment with the Bureau ended, you must list your post-CFPB employment history and earnings in Section N and provide evidence of these earnings (e.g., W-2 form, 1099 form, tax return, Social Security Wage Statement, etc.). When completing this Claim Form, state which position you held during each incident you describe. You have been provided a work history listing details about each position you held while working at the Bureau from February 13, 2011 through December 31, 2022, which you can use to help fill out this Claim Form. You may also submit a statement or documentation with respect to any positions you held while working at the Bureau from January 1, 2023 through September 15, 2023. Some of the questions refer to “covered positions” and “non-covered positions.” You can use the work history to determine if a position you held between February 13, 2011 and December 31, 2022, is covered or non-covered, and positions you held from January 1, 2023 through September 15, 2023 may also be covered for purposes of the Discretionary Award. A covered position is a position that is non-supervisory, located in the Office of Consumer Response, in job series 301, and with a pay band of 40-60, except that the following positions are not covered positions: Consumer Response Implementation Manager (associated with position description number 110090), Consumer Response Manager (Quality Control) (associated with position description number 111410), Policy Analyst (associated with position description number 110210), or Consumer Response Analyst (associated with position description number 110770). A non-covered position is a position that does not meet the above criteria. You must sign the Claim Form under penalty of perjury and the Claims Administrator must receive it by April 1, 2024. The Jones et al. v. Chopra et al. lawsuit alleged that the Consumer Financial Protection Bureau ("CFPB" or the "Bureau") engaged in systemic discrimination against Black/African American and Hispanic employees who worked in certain positions in the Office of Consumer Response. In the lawsuit, Plaintiffs challenged several CFPB policies and practices as discriminatory against such Black/African American and Hispanic employees, including those relating to compensation and movement within the Bureau. Plaintiffs also alleged the Bureau retaliated against employees who complained of racial discrimination or engaged in other protected equal employment opportunity ("EEO") activity. The Bureau denied these allegations. Instead of continuing to litigate this case, the parties settled this lawsuit. This Claim Form is intended to assist you in providing information about how, if at all, you believe you were subjected to discrimination, a hostile work environment, or harassment by the Bureau because you are Black/African American and/or Hispanic, or were retaliated against by the Bureau for protected EEO activity, and what losses and harm you suffered as a result. You may not have experienced some of the topics addressed below. You need only respond to questions that apply to you. If you believe you experienced discrimination because you are Black/African American and/or Hispanic and/or retaliation for protected EEO activity in ways not specifically addressed below, please include additional information in Section P, using additional pages if needed, in order to fully set forth your claim of discrimination on the basis of your Black/African American and/or Hispanic race and/or ethnicity and/or claim of retaliation for protected EEO activity. ClaimFormNoHiddenHiddenLastName* Claimant ID* Name* First Last Current Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Personal email address (you will be emailed a copy of your completed claim form)* Daytime Telephone Number* A. EDUCATIONAL HISTORY (College and above)SchoolDegreeDate Add RemoveB. PRIOR RELEVANT EMPLOYMENTPre-CFPB Relevant Professional EmploymentEmployerDates of EmploymentJob(s) Held Add RemoveDescribe your career achievements prior to your employment with CFPB. C. CFPB EMPLOYMENT 1. Are you currently employed by the Bureau? Yes No No Answer 2. You have been provided with a work history covering your employment at the Bureau between February 13, 2011 and December 31, 2022. If you believe that this work history is inaccurate in any way, please explain how and provide supporting documentation.3. If you worked for the Bureau in a covered position between January 1, 2023 and September 15, 2023, please identify any position(s) you held, and for each position, identify the office to which it was assigned, the job series, the pay band you were in, whether the position was supervisory, and the dates you held that position. You may but are not required to provide supporting documentation available to you. If you were not in a covered position during this timeframe, you do not need to provide this information.4. If you are not a current Bureau employee, explain the reason for your separation from the Bureau (e.g. termination, resignation, forced to resign, medical, layoff, contract non-renewal). D. HIRING & PAY SETTING This lawsuit alleged that Black/African American and Hispanic Bureau employees in the Office of Consumer Response were harmed in the hiring process, including with respect to the position(s) they were hired into, the pay band for such position(s), pay setting within the pay band, whether the position had a career ladder, and if so, what that career ladder was. (A career ladder allows employees to move from one pay band to the next without a competitive process. For example, a career ladder of 40 to 52 would allow an employee to noncompetitively move from pay band 40 to 51 to 52). INSTRUCTIONS You can use the work history to determine if a position you held between February 13, 2011 and December 31, 2022, is covered or non-covered, and positions you held from January 1, 2023 through September 15, 2023 may also be covered for purposes of the Discretionary Award. A covered position is a position that is non-supervisory, located in the Office of Consumer Response, in job series 301, and with a pay band of 40-60, except that the following positions are not covered positions: Consumer Response Implementation Manager (associated with position description number 110090), Consumer Response Manager (Quality Control) (associated with position description number 111410), Policy Analyst (associated with position description number 110210), or Consumer Response Analyst (associated with position description number 110770). A non-covered position is a position that does not meet the above criteria. 1. Prior to working in a covered position, did you work in a non-covered position? (A covered position is a position that meets the class definition. Please refer to the instructions above or at the beginning of this form for a full definition of “covered position.”) Yes No No Answer If yes, answer question D.2; if no, proceed to question D.32. Do you believe that time you spent in a non-covered position negatively impacted your career and/or earnings in a covered position? If yes, please explain how time you spent in a non-covered position impacted your career and/or pay in a covered position.3. Do you believe you were treated less favorably because you are Black/African American and/or Hispanic during the hiring process into a covered position, including with respect to the position assigned, the pay band assigned, the pay setting within the pay band, and any career ladder assigned? If yes, please describe, including when this treatment occurred and with respect to which positions.4. Do you believe that any of the issues identified above have had any impact on your subsequent career and/or earnings? If yes, please explain how your career and earnings have been affected. E. PERFORMANCE REVIEWS This lawsuit alleged that the Bureau's performance evaluation system harmed Black/African American and Hispanic employees by giving them lower scores on performance reviews than white employees for similar work. 1. Did you receive a performance review in 2012 or 2013? Yes No No Answer If yes, answer question E.2, if not proceed to question E.32. In 2014, the Bureau made remediation payments to employees who received a 3 or 4 summary performance rating in 2012 and 2013. Do you believe you received an unfair performance review in 2012 or 2013 because you are Black/African American and/or Hispanic that caused harm for which you have not already been compensated? If yes, please describe in detail how and why you believe the performance review was unfair and the harm you believe was not fully compensated.3. Do you believe you received any unfair performance reviews not identified above because you are Black/African American and/or Hispanic? If yes, please identify the years in which you received performance reviews you believe were unfair and describe in detail how and why you believe the performance review(s) was unfair and the harm you believe was caused. F. MOVEMENTS AND PROMOTIONS This lawsuit alleges that Black/African American and Hispanic employees were treated less favorably with respect to movements and promotions. This includes both movement within a career ladder (e.g., being noncompetitively moved from pay band 51 to 52) and promotions to different positions within the Bureau. 1. If you held a position with a career ladder, do you believe you had any difficulty moving from one pay band to the next because you are Black/African American and/or Hispanic? If yes, please describe in detail the difficulties you believe you faced, including the position and year at issue, and the harm you believe this caused.2. Do you believe you were not promoted or had difficulty being promoted because you are Black/African American and/or Hispanic? If yes, please describe in detail the promotion(s) you believe you were denied or had issues with because you are Black/African American and/or Hispanic and the underlying circumstances, including when these events occurred, all persons involved, the harm you believe was caused (including difference in pay), and any examples of similar non–African American or non-Hispanic employees who were promoted.3. Do you believe that any of the issues regarding movements and/or promotions you identified above have had any impact on your subsequent career and/or earnings? If yes, please explain how your career and earnings have been affected. G. DETAILS AND SPECIAL PROJECTS This lawsuit alleged that Black/African American and Hispanic employees were treated less favorably with respect to details and special projects, including by being denied detail assignments and special projects that were critical for promotion and increased earning potential. 1. Do you believe that you were treated less favorably with respect to any details and/or special projects because you are Black/African American and/or Hispanic? If yes, please describe any such detail and/or special project and the underlying circumstances in detail, including when they occurred.2. Do you believe that any of the issues regarding detail assignments and/or special projects you identified above have had any impact on your subsequent career and/or earnings? If yes, please explain how your career and earnings have been affected. H. TRAINING AND CAREER DEVELOPMENT OPPORTUNITIES This lawsuit alleged that Black/African American and Hispanic employees were treated less favorably with respect to training and other career development opportunities, including by being denied trainings that were offered to white employees. 1. Do you believe that you were treated less favorably with respect to any training or other career development opportunities because you are Black/African American and/or Hispanic? If yes, please describe any such opportunities and underlying circumstances in detail, including when they occurred.2. Do you believe that any of the issues regarding training and other career development opportunities you identified above have had any impact on your subsequent career and/or earnings? If yes, please explain how your career and earnings have been affected. I. RACIAL HARASSMENT/HOSTILE WORK ENVIRONMENT This lawsuit alleged that Black/African American and Hispanic employees were subjected to a racially hostile work environment. Do you believe that you were subjected to harassment or a hostile work environment because you are Black/African American and/or Hispanic? If yes, describe in detail how you believe you were harassed and/or examples of what you believe made your work environment hostile. Include in your response specific statements made, by and to whom they were made, conduct you believe was harassing, approximate dates of such statements and conduct, and the individuals engaged in the conduct, among other relevant details.1. Did you ever hear, or were you ever the subject of race- or ethnicity-based remarks directed at Black/African American and/or Hispanic employees at the Bureau? Yes No No Answer If yes, please describe the circumstances in detail, including identifying all persons involved, when the statements occurred, and how they impacted your work environment. I.1 Conditional if yes, describe2. Other than your response to the above questions, did you learn about race- or ethnicity-based remarks or hostility directed toward other Black/African American and/or Hispanic employees at the Bureau that impacted your work environment? Yes No No Answer If yes, please describe the circumstances in detail, including identifying all persons involved, when they occurred, and how they impacted your work and environment.I.2 Conditional if yes, describe3. Do you believe any treatment, incidents, or remarks you identified above have had any impact on your subsequent career and/or earnings? If yes, please explain how your career and earnings have been affected. J. RETALIATION FOR COMPLAINTS OF RACIAL DISCRIMINATION AND OTHER PROTECTED EEO ACTIVITY This lawsuit alleged that Black/African American and Hispanic employees who complained about their treatment or engaged in other protected EEO activity were retaliated against, including by being subjected to further discrimination and harassment, and by being terminated or refused a contract extension. 1. Did you engage in any protected EEO activity, such as by making any internal complaints about discrimination based on your race and/or ethnicity or complaints about retaliation? If yes, please describe your activity or your complaint(s) in detail, including by identifying when and to whom you complained (e.g., to management, human resources, etc.) or engaged in the protected EEO activity.2. Describe any action taken regarding the complaints or other protected activity you identified above (e.g., whether there was an investigation, finding, or any corrective action taken by the Bureau).3. Have you ever filed an Equal Employment Opportunity administrative complaint or union grievance against the Bureau regarding discrimination based on your race and/or ethnicity or regarding retaliation? If yes, please state when you filed the complaint or grievance and the entity with which you filed, and describe the nature of your allegations and how the matter was resolved.4. Have you ever filed a lawsuit against the Bureau alleging discrimination based on your race and/or ethnicity or alleging retaliation? If yes, please state when you filed the lawsuit and describe the nature of your allegations and how the matter was resolved.5. After you made the complaints or engaged in the other protected EEO activity identified above, do you believe you were subjected to retaliation? If yes, describe the circumstances in detail, including when the retaliation occurred, all persons involved, and any adverse action taken against you. K. TERMINATION/SEPARATION (IF APPLICABLE) This lawsuit alleges that Black/African American and Hispanic employees were unfairly terminated, were unfairly denied contract extensions or conversions from “term” employment to a “perm” employment, or resigned because of unfair treatment and/or harassment based on their race and/or ethnicity. 1. What was the reason for your departure from the Bureau? Include whether you were a “term” employee who did not have their contract extended or were not converted to a permanent employee. If you resigned, include your reasons for leaving the Bureau.2. Were you given the option to resign rather than be terminated? Yes No No Answer L. EMOTIONAL DISTRESS In order to receive an award for emotional distress, you must complete this section of the claim form. You may but are not required to submit documentation regarding your emotional distress, such as medical records. 1. Have you suffered emotional distress that you believe is the result of any discrimination you believe you experienced at the Bureau because you are Black/African American and/or Hispanic or is the result of any retaliation you believe you experienced at the Bureau because you engaged in protected EEO activity? If yes, describe in detail the emotional distress suffered and its impact.2. Did you or do you have any physical manifestations from the emotional distress you described above? (For example, headaches, hives, or nausea.) If yes, describe these in detail.3. Did you seek advice or care from a doctor, counselor, or other medical professional for any emotional distress described above? If yes, describe in detail the advice or care you sought and received.4. Were you prescribed medication due to your emotional distress described above? Yes No No Answer 5. Do you continue to experience symptoms or have permanent detrimental health effects from any discrimination or retaliation that you believe you experienced? If yes, please describe your symptoms or the permanent health effects. M. LOSSES 1. Were you forced to file for bankruptcy or did you have a home foreclosure, IRS action, or other catastrophic financial event due to your experience at the Bureau? Yes No No Answer 2. If yes, describe the events and circumstances (including how you believe that your experience at the Bureau contributed to those events).3. Did you suffer any period of unemployment after separating from the Bureau? If yes, for how long were you unemployed, and did you receive unemployment benefits? Please also describe your efforts to find employment during any such period, including the positions for which you applied and the expected compensation for any employment that you were offered but declined.4. If not otherwise set forth above, describe how you believe you have been financially harmed by any discrimination you believe you experienced at the Bureau because you are Black/African American and/or Hispanic or by any retaliation you believe you experienced at the Bureau because you engaged in protected EEO activity. N. SUBSEQUENT EMPLOYMENT/EARNINGS (Former Bureau Employees Only) 1. If you wish for the Neutral to consider losses that you have suffered after your employment with the Bureau ended, you must list your post-CFPB employment history and earnings and provide evidence of these earnings (e.g., W-2 form, 1099 form, tax return, Social Security Wage Statement, etc.). Employment ListEmployerDates of EmploymentJob(s) HeldCompensation Add Remove2. List your annual earnings for every year following your separation from the Bureau. O. OTHER FORMAL AND INFORMAL LITIGATION AND SETTLEMENTS/RELEASES 1. Have you ever formally or informally asserted legal claims against the Bureau? If yes, describe the nature of the legal claims and how you asserted those claims (e.g., whether you wrote a letter, contacted the Bureau’s Office of Civil Rights (EEO office), hired a lawyer, attended a mediation, or took other steps).2. Have you ever been in litigation against the Bureau? If yes, describe the claims asserted and the outcome of the litigation.3. Have you ever signed an agreement or settlement releasing any claims against the Bureau? If yes, describe the date and scope of the release, including whether the release included claims of discrimination based on race and/or ethnicity or claims of retaliation and provide a copy if possible. Also describe the circumstances leading to the release agreement, including whether you filed a claim against the Bureau, the type of claim (e.g., racial discrimination or retaliation, breach of contract, etc.), and whether you were represented by a lawyer or assisted by a government agency.4. At the time you signed the release agreement, were you aware of this class action lawsuit? Yes No No Answer 5. Did you incur any legal costs and/or have any ongoing financial liability as a result of any legal action described above? If yes, please state the amount of your legal costs and any ongoing liability for legal fees and expenses. P. ADDITIONAL INFORMATION 1. Please explain any additional facts or information supporting your claim of discrimination or harassment based on your Black/African American and/or Hispanic race and/or ethnicity or your claim of retaliation or any additional information that you wish the Neutral to consider in understanding your experiences at the Bureau and the losses you suffered. When describing specific incidents, remember to include when they occurred and the position you held. You may attach additional pages to complete your statement.Upload Supporting Documents for Claim Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB, Max. files: 20. You may be required to submit additional information or documents if needed to fully evaluate your claim. By signing I swear under penalty of perjury that the foregoing information is true and accurate to the best of my knowledge and belief If you have any questions regarding the Settlement or this Claim Form, you can contact the Claims Administrator or Class Counsel: CFPB Claims Administrator c/o Atticus Administration PO Box 64053 Saint Paul, MN 55164 Stowell & Friedman, Ltd., Class Counsel 1-312-431-0888 Unique ID
