**SSA-437-BK Civil Rights Complaint Form – Draft** 1. **Complainant’s Name:** Clifford Ray Hackett 2. **Mailing Address:** General Delivery 3. **City, State, and ZIP Code:** Barrigada, Guam 9691 3 4. **Telephone Number:** 671-787-2345 5. **Alternate Phone Number:** _(left blank)_ 6. **Email Addre ss:** 3659745@gmail.com 7. **Name of Individual Discriminated Against:** Jane Doe 8. **Their Address:** _(unknown)_ 9. **Their City, State, ZIP Code:** _(unknown)_ 10. **Their Phone Number:** _(unknown)_ 11 . **Relationship to the person discriminated against:** Advocate 12. **Who discriminated against you:** Na me unknown – Employee at Guam Social Security Office 13. **Location where discrimination occurred: ** Guam Social Security Office 14. **Date(s) of alleged discrimination:** June 17, 2025 15. **Describe t he act(s) of discrimination:** On June 17, 2025, I personally handed my ID to an SSA employee at the Guam Social Security Office. The next day, she refused to return it. I contacted the Guam Airport Police, who int ervened and recovered the ID. The incident was documented under case number 2515312. I believe this refusal was unjustified and possibly discriminatory. 16. **Basis of discrimination (check all that apply):** _(To be determined—consider age, disability, national origin, etc. if applicable)_ 17. **Have efforts b een made to resolve this with SSA?** Yes. I contacted the Guam Airport Police, who intervened and recovere d my ID. The incident is recorded under case number 2515312, but SSA has not responded or addressed it. 18 . **Have you filed this complaint with any other federal, state, or local agency?** No 19. **If yes, provi de details:** _(Not applicable)_ 20. **What remedy or resolution are you seeking?** I am requesting the immediate termination of the SSA employee involved. I have endured over a decade of harm traceable to someon e inside the Social Security system, and I now believe this employee may be responsible. 21. **Signature:* * Clifford Ray Hackett 22. **Date:** _(To be signed on submission)_