SF-85P Questionnaire for Public Trust Positions

Form approved:
OMB No. 3206 0005
NSN 7540-01-317-7372
86-111

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Questionnaire for Public Trust Positions
Follow instructions fully or we cannot process your form. If you have any questions, contact the office that gave you the form.

Purpose of this Form

Instructions for Completing this Form

The United States Government conducts background investigations and
reinvestigations to establish that applicants or incumbents either employed by
the Government or working for the Government under contract are suitable for
the job and/or eligible for a public trust position.

1.

Giving us this information is voluntary. However, we may not be able to complete your investigation, or complete it in a timely manner, if you don’t give us
each item of information we request. This may affect your placement or employment prospects. Any information that you provide is evaluated regarding its
recency, seriousness, relevance to the position and duties, and in light of
– and in relationship to – all other information about you.
Withholding, misrepresenting, or falsifying information will have an impact on
your employment prospects, or job status, up to and including removal and
debarment from Federal Service.

Authority to Request this Information
Depending upon the purpose of your investigation, the United States
Government is authorized to ask for this information under Executive Order
10450; sections 3301, 3302, and 9101 of title 5, United States Code; and parts
2, 5, 731, and 736 of title 5, Code of Federal Regulations.
Your Social Security Number (SSN) is needed to keep records accurate
because other people may have the same name and birth date. Disclosure of
your SSN will be used to help identify you in agency records. Although
disclosure of your SSN is not mandatory, failure to disclose your SSN may
prevent or delay the processing of your background investigation. We may
verify your SSN with the Social Security Administration. The authority for
soliciting and verifying your SSN is Executive Order 9397.

The Investigative Process
Background investigations for public trust positions are conducted to develop
information to show whether you are reliable, trustworthy, of good conduct and
character, and loyal to the United States. The information that you provide on
this form may be confirmed during the investigation. The investigation may
extend beyond the time covered by this form when necessary to resolve issues.
Your current employer may be contacted as part of the investigation, even if you
have previously indicated on applications or other forms that you do not want
your current employer to be contacted.

Your Personal Interview
Some investigations will include an interview with you as a routine part of the
investigative process. The investigator may ask you to further explain your
answers to any question on this form. This provides you the opportunity to
update, clarify, and explain information on your form more completely, which
often helps to complete your investigation faster. It is important that the
interview be conducted as soon as possible after you are contacted.
Postponements will delay the processing of your investigation and declining to
be interviewed may result in your investigation being delayed or canceled.
For the interview, you will be asked to bring identification with your picture on it,
such as a valid state driver's license. There are other documents you may be
asked to bring to verify your identity. These may include documentation of any
legal name change, Social Security card, passport, and/or your birth certificate.
You may also be asked to bring documents about information you provided on
the form or other matters requiring specific attention. These matters include
alien registration or naturalization documentation; delinquent loans or taxes,
bankruptcy, judgments, liens, or other financial obligations; agreements
involving child custody or support, alimony, or property settlements; arrests,
convictions, probation, and/or parole; or other matters described in court
records.

Follow the instructions given to you by the office that gave you this form and any
other clarifying instructions furnished by that office to assist you in completion of
this form. Determine how many copies of the form you should submit. You must
sign and date, in black ink, the original and each copy you submit. You should
retain a copy of the completed form for your records.

2. Type or legibly print your answers in black ink (if this form is not legible, it will not
be accepted). You may also be asked to submit your form using Electronic
Questionnaires for Investigations Processing (e-QIP), the Office of Personnel
Management’s (OPM) web-based system application that houses electronic
versions of this form.
3. All questions on this form must be answered. If no response is necessary or
applicable, indicate this on the form with “N/A”.
4. Any changes that you make to this form after you sign it must be initialed and
dated by you. Under certain limited circumstances, agencies may modify your
response(s) consistent with your intent.
5. You must use the State codes (abbreviations) listed on the back of this page
when you fill out this form. Do not abbreviate the names of cities or foreign
countries.
6. Whenever “City (Country)” is shown in an address block, provide in that block the
name of the country when the address is outside the United States.
7. The 5-digit postal ZIP codes are needed to speed the processing of your
investigation. The office that provided this form will assist you in completing the
ZIP codes.
8. For telephone numbers in the United States, be sure to include the area code.
9. All dates provided on this form must be in Month/Day/Year or Month/Year format.
Use numbers (1-12) to indicate months. For example, October 27, 2002, should
be written as 10/27/2002. If you find that you cannot report an exact date,
approximate or estimate the date to the best of your ability and indicate this by
writing “APPROX.” or “EST.”
10. If you need additional space to list your residences, employment/selfemployment/unemployment, or education, you should use a continuation sheet,
SF 86A. If additional space is needed to answer other items, use a blank piece of
paper. Each blank piece of paper you use must contain your name and SSN at
the top of the page.

Final Determination on Your Eligibility
Final determination on your eligibility for a public trust position is the
responsibility of the Federal agency that requested your investigation. You may
be provided the opportunity personally to explain, refute, or clarify any
information before a final decision is made.

Penalties for Inaccurate or False Statements
The United States Criminal Code (title 18, section 1001) provides that knowingly
falsifying or concealing a material fact is a felony which may result in fines
and/or up to 5 years of imprisonment. In addition, Federal agencies generally
fire or disqualify individuals who have materially and deliberately falsified these
forms, and this remains a part of the permanent record for future placements.
Your trustworthiness is a very important consideration in deciding your eligibility.
Your prospects of placement are better if you answer all questions truthfully and
completely. You will have adequate opportunity to explain any information you
give us on the form and to make your comments part of the record.

Disclosure of Information
The information you give us is for the purpose of determining your suitability for
Federal employment; we will protect it from unauthorized disclosure. The
collection, maintenance, and disclosure of background investigative information
is governed by the Privacy Act. The agency that requested the investigation
and the agency that conducted the investigation have published notices in the
Federal Register describing the systems of records in which your records will be
maintained. The information on this form, and information collected during an
investigation, may be disclosed without your consent by an agency maintaining
the information in a system of records as permitted by the Privacy Act [5 U.S.C.
552a(b)], and by routine uses published by the agency in the Federal Register.
The office that gave you this form will provide you a copy of its routine uses, if
they are different than those listed on this form.

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No. 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS
PRIVACY ACT ROUTINE USES

OPM has published routine uses for disclosing background information in OPM’s systems of investigative records. OPM conducts the majority of background
investigations and serves as the lead agency for the SF 85P. OPM’s routine uses follow:

•

•

•

•
•
•

•

•

•
•

To designated officers and employees of agencies, offices, and other establishments in the
executive, legislative, and judicial branches of the Federal Government, having a need to evaluate
qualifications, suitability, and loyalty to the United States Government and/or a security clearance
access or determination.
To designated officers and employees of agencies, offices, and other establishments in the
executive, legislative, and judicial branches of the Federal Government, when such agency, office,
or establishment conducts an investigation of the individual for purposes of granting a security
clearance, or for the purpose of making a determination of qualifications, suitability, or loyalty to the
United States Government, or access to classified information or restricted areas.
To designated officers and employees of agencies, offices, and other establishments in the
executive, judicial, or legislative branches of the Federal Government, having the responsibility to
grant clearances to make a determination regarding access to classified information or restricted
areas, or to evaluate qualifications, suitability, or loyalty to the United States Government, in
connection with performance of a service to the Federal Government under a contract or other
agreement.

•

•
•

•

To the intelligence agencies of the Department of Defense, the National Security Agency, the
Central Intelligence Agency, and the Federal Bureau of Investigation for use in intelligence
activities.
To any source from which information is requested in the course of an investigation, to the extent
necessary to identify the individual, inform the source of the nature and purpose of the
investigation, and to identify the type of information requested.
To the appropriate Federal, State, local, tribal, foreign, or other public authority responsible for
investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order where
OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or
regulation.
To an agency, office, or other establishment in the executive, legislative, or judicial branches of the
Federal Government, in response to its request, in connection with the hiring or retention of an
employee, the issuance of a security clearance, the conducting of a security or suitability
investigation of an individual, the classifying of jobs, the letting of a contract, or the issuance of a
license, grant, or other benefit by the requesting agency, to the extent that the information is
relevant and necessary to the requesting agency's decision on the matter.
To provide information to a congressional office from the record of an individual in response to an
inquiry from the congressional office made at the request of that individual. However, the
investigative file, or parts thereof, will only be released to a congressional office if OPM receives a
notarized authorization or signed statement under 28 U.S.C. 1746 from the subject of the
investigation.
To the Office of Management and Budget (OMB) at any stage in the legislative coordination and
clearance process in connection with private relief legislation as set forth in OMB Circular No. A-19.
To disclose information to contractors, grantees, experts, consultants, or volunteers performing or
working on a contract, service, or job for the Federal Government.

•

•

•

For Judicial/Administrative Proceedings--To disclose information to another Federal agency,
to a court, or a party in litigation before a court or in an administrative proceeding being
conducted by a Federal agency, when the Government is a party to the judicial or
administrative proceeding. In those cases where the Government is not a party to the
proceeding, records may be disclosed if a subpoena has been signed by a judge.
For National Archives and Records Administration--To disclose information to the National
Archives and Records Administration for use in records management inspections.
Within OPM for Statistical/Analytical Studies--By OPM in the production of summary
descriptive statistics and analytical studies in support of the function for which the records are
collected and maintained, or for related workforce studies. While published studies do not
contain individual identifiers, in some instances the selection of elements of data included in
the study may be structured in such a way as to make the data individually identifiable by
inference.
For Litigation--To disclose information to the Department of Justice, or in a proceeding before
a court, adjudicative body, or other administrative body before which OPM is authorized to
appear, when
(1)

OPM, or any component thereof; or

(2)

Any employee of OPM in his or her official capacity; or

(3)

Any employee of OPM in his or her individual capacity where the Department of Justice
or OPM has agreed to represent the employee; or

(4)

The United States, when OPM determines that litigation is likely to affect OPM or any of
its components; is a party to litigation or has an interest in such litigation, and the use of
such records by the Department of Justice or OPM is deemed by OPM to be relevant
and necessary to the litigation provided, however, that the disclosure is compatible with
the purpose for which records were collected.

For the Merit Systems Protection Board--To disclose information to officials of the Merit
Systems Protection Board or the Office of the Special Counsel, when requested in connection
with appeals, special studies of the civil service and other merit systems, review of OPM rules
and regulations, investigations of alleged or possible prohibited personnel practices, and such
other functions, e.g., as promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by
law.
For the Equal Employment Opportunity Commission--To disclose information to the Equal
Employment Opportunity Commission when requested in connection with investigations into
alleged or possible discrimination practices in the Federal sector, compliance by Federal
agencies with the Uniform Guidelines on Employee Selection Procedures or other functions
vested in the Commission and to otherwise ensure compliance with the provisions of 5 U.S.C.
7201.
For the Federal Labor Relations Authority--To disclose information to the Federal Labor
Relations Authority or its General Counsel when requested in connection with investigations
of allegations of unfair labor practices or matters before the Federal Service Impasses Panel.

STATE CODES
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia

AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA

Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland

HI
ID
IL
IN
IA
KS
KY
LA
ME
MD

American Samoa
Palau

AS
PW

Federated States of Micronesia FM
Puerto Rico
PR

Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey

MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ

Guam
GU
Virgin Islands of the U.S. VI

New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina

NM
NY
NC
ND
OH
OK
OR
PA
RI
SC

South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

Marshall Island

MH

Northern Mariana Islands MP

PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information averages 60 minutes, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street NW,
Washington, DC 20415. Do not send your completed form to this address, send it to the office that provided you the form. The OMB clearance number, 3206-0005,
is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

I certify that I have carefully read the foregoing instructions to complete this form.

Signature

Date (mm/dd/yyyy)

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Investigating agency use only

Codes

Case number

AGENCY USE ONLY (Complete items A through S using Instructions provided by the investigating agency.)

A

Type of investigation

G

Geographic location

B

C

Extra coverage

H

J

SON

K

L

SOI

M

N

D

Sensitivity level

I

Position code

Access/Eligibility

E

F

Nature of action code

Date of action (mm/dd/yyyy)

Position title
Zip Code

IPAC number

Other address / Web address
Location of official personnel folder
None
At SON
NPRC
e-OPF
Other address
Location of security folder
None
At SOI
NPI
O Accounting data and/or Agency case number

P

Q

Requesting official

Name and title

Signature

Initial
Reinvestigation
Telephone number
Date (mm/dd/yyyy)

R

Processing official

Name and title

Telephone number

S

Zip Code

(

(

1 FULL NAME
Last name

)

Middle name

MIL

Other

2 DATE OF BIRTH

- If you have no middle name, enter “NMN.”

(mm/dd/yyyy)

Jr., II, etc.

3 PLACE OF BIRTH

4 SOCIAL SECURITY NUMBER

City

County

Name

)
Investigation
FED

- If you have only initials in your name, use them and state (I/O).
- If you are a ‘”Jr.,” Sr.,” etc., enter this in the box after your middle name.
First name

5 OTHER NAMES USED –

Type of investigation

State

Country (If not in the U.S.)

Give other names you used and the period of time you used them [for example: your maiden name, name(s) by a former marriage, former name(s),
alias(es), or nickname(s)]. If the other name is your maiden name, put “nee” in front of it.
Month/Year
To
Month/Year
Name
Month/Year
To
Month/Year

#1

#3

Name

Month/Year

To

Month/Year

Name

#2

Month/Year

To

Month/Year

#4

6 MOTHER’S BIRTH NAME

Last name

7 YOUR IDENTIFYING INFORMATION

First name

Height (feet and inches )

Weight (pounds)

Middle name

Hair color

Eye color

Sex

 Female

 Male

8 CONTACT INFORMATION
Work e-mail address

Home e-mail address
Home telephone number

Work telephone number
(

)

9 CITIZENSHIP –

 Day

 Night

(

)

Mobile telephone number

 Day

 Night

(

)

 Day

 Night

Mark the box that reflects your current citizenship status and follow its instructions. Report information from U.S. Passport, if applicable.

 I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
 I am a U.S. citizen by birth, born outside the U.S……………………………………………………….Answer item 9A
 I am a naturalized U.S. citizen…………………………………………………………………………….Answer item 9B
 I am not a U.S. citizen………………………………………………………………………………………Answer item 9C

U.S. PASSPORT

Number

Date issued (mm/dd/yyyy)

Current or most recent passport

Expired?
 YES

 NO

9A STATE DEPARTMENT FORM 240 (Report of Birth Abroad of a Citizen of the United States)
Report information from Form 240, if applicable.

Date form was completed (mm/dd/yyyy)

Explanation

9B

City/Court

State

Certificate number

Date issued (mm/dd/yyyy)

Expired?

City/Court

State

Certificate number

Date issued (mm/dd/yyyy)

 YES  NO
Expired?

CITIZENSHIP CERTIFICATE
Where was this certificate issued?

NATURALIZATION CERTIFICATE
Where was this certificate issued?

9C

 YES

IMMIGRATION STATUS

City

Place of entry
Date of document (mm/dd/yyyy)

Type of document

State
Document number

Enter your Social Security Number before going to the next page
Page 1

Date of entry (mm/dd/yyyy)
Country(ies) of citizenship

 NO

Standard Form 85P
Revised December 2005
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No. 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

10 CITIZENSHIP INFORMATION
Do you now hold or have you ever held multiple citizenships?

 YES  NO

(If No, proceed to question 11.)

A If “Yes,” provide the name(s) of the country(ies).

D Why have you held multiple citizenships?

B During what periods of time did you hold multiple citizenships?

E Have you renounced or attempted to renounce your foreign citizenship?
 YES  NO

C How were multiple citizenships obtained?

11 WHERE YOU HAVE LIVED
List the places where you have lived, beginning with your present residence (#1) and working back 7 years. All periods must be accounted for without breaks. Indicate
the actual physical location of your residence. Do not use a Post Office Box as an address, and do not list a permanent address when you were actually living at a
school address, etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or home port. You
may omit temporary military duty locations under 90 days (list your permanent address instead). Your actual physical address in addition to your APO/FPO address is
required for overseas assignments.
For any address in the last 5 years, list a person who knew you at that address, and who preferably still lives in that area. Do not list people for residences completely
outside this 5-year period, and do not list your spouse, former spouse, or other relatives. Also for addresses in the last 5 years, if the address is “General Delivery,” a
Rural or State Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet (SF 86A). Do not list residences before
your 18th birthday unless to provide a minimum of 2 years of residence history.

Residence Information
Month/Year

To

Month/Year

#1
Present

Status
 Own
 Rent

Street address

Point of Contact for that Period of Residence
Name of person who knows you (last, first)
 Military Housing
 Other
Apt. #

APO/FPO address

#2

State

To

Month/Year

Status
 Own
 Rent

Street address

Zip Code

 Military Housing
 Other
Apt. #

State
To

Month/Year

#3

Status
 Own
 Rent

Street address

Zip Code

City (Country)

State

 Military Housing
 Other
Apt. #

Current address

State
To

Month/Year

Status
 Own
 Rent

Zip Code

City (Country)

State

Name of person who knows you (last, first)
 Military Housing
 Other
Apt. #

Current address

(
Relationship
 Neighbor
 Friend
Apt. #

Zip Code

City (Country)

State

Zip Code

Page 2

)

Alternate contact number

Relationship
 Neighbor
 Friend
Apt. #

)
 Landlord
 Business Associate
 Other
Telephone number
(

Zip Code

)

Alternate contact number

(
)
Relationship
 Landlord
 Neighbor
 Business Associate
 Friend
 Other
Apt. #
Telephone number
(

Zip Code

)

Alternate contact number
(

Enter your Social Security Number before going to the next page

)
 Landlord
 Business Associate
 Other
Telephone number
(

APO/FPO address (if currently applicable)
State

)

Alternate contact number

(

APO/FPO address
City (Country)

Zip Code

APO/FPO address (if currently applicable)

City (Country)

Street address

Current address

Name of person who knows you (last, first)

APO/FPO address

#4

State

APO/FPO address (if currently applicable)

City (Country)

Month/Year

City (Country)

Name of person who knows you (last, first)

APO/FPO address

Month/Year

(

APO/FPO address (if currently applicable)

City (Country)

Month/Year

Current address

Relationship
 Landlord
 Neighbor
 Business Associate
 Friend
 Other
Telephone number
Apt. #

)

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No. 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

12 WHERE YOU WENT TO SCHOOL
List the schools you have attended, beginning with the most recent (#1) and working back 7 years. List college or university degrees and the dates they were
received. If all of your education occurred more than 7 years ago, list your most recent Degree/Diploma including high school, no matter when that education
occurred.

In the Code block, show the most appropriate code to describe your school.
1 – High School
2 – College/University/Military College
3 – Vocational/Technical/Trade School
4 – Correspondence/Distance/Extension/Online School

For Correspondence/Distance/Extension/Online schools, provide the address where the records are maintained.

For schools you attended in the past 7 years, list a person who knew you at school (instructor, student, etc.).
Do not list people for education completely outside this 7-year period.

12A School Information
#1

Month/Year

To

Month/Year

Code

Degree/Diploma received?  YES  NO
(If “Yes,” explain, include mm/yyyy awarded.)

Name of school

Street address and City (Country) of school

State

Name of person who knew you (last, first)

#2

Month/Year

To

Month/Year

Current address
Code

Apt. #

City (Country)

State

State
Current address

Name of person who knew you (last, first)

#3

To

Month/Year

Code

Apt. #

City (Country)

State

#4

Month/Year

To

Month/Year

State
Current address
Code

Apt. #

City (Country)

State

#5

Month/Year

To

Month/Year

Current address

Apt. #

City (Country)

State

ZIP Code
Telephone number

ZIP Code

ZIP Code
Telephone number

(
)
Degree/Diploma received?  YES  NO
(If “Yes,” explain, include mm/yyyy awarded.)

Name of school

Street address and City (Country) of school
Name of person who knew you (last, first)

ZIP Code

State

Code

Telephone number

(
)
Degree/Diploma received?  YES  NO
(If “Yes,” explain, include mm/yyyy awarded.)

Name of school

Street address and City (Country) of school
Name of person who knew you (last, first)

ZIP Code

ZIP Code

(
)
Degree/Diploma received?  YES  NO
(If “Yes,” explain, include mm/yyyy awarded.)

Name of school

Street address and City (Country) of school
Name of person who knew you (last, first)

Telephone number

(
)
Degree/Diploma received?  YES  NO
(If “Yes,” explain, include mm/yyyy awarded.)

Name of school

Street address and City (Country) of school

Month/Year

ZIP Code

ZIP Code

State
Current address

Apt. #

City (Country)

State

ZIP Code

ZIP Code
Telephone number
(

12B Suspension or Expulsion
Were you suspended or expelled from any of the institutions above?  YES
If “Yes,” explain. Do not include academic probations.

 NO

Enter your Social Security Number before going to the next page
Page 3

)

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No. 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

13 EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 7 years. You should list all full-time and part-time work, paid or unpaid,
consulting/contracting work, military service, temporary military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment.
The entire period must be accounted for without breaks. EXCEPTION: Do not list employments before your 18th birthday unless to provide a minimum of 2 years
of employment history. If you require additional space, use a continuation sheet (SF 86A).





Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this
block. If military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to
reflect changes in your military duty locations or home ports. If you are a Federal Contractor, list contract, not Federal Agency.



Additional Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most
recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For
example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent
period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.

Code: If this is a former employment or if you intend to leave this position, indicate your reason for leaving.
1 – Left job under favorable circumstances
3 – Left job by mutual agreement following notice
2 – Left job by mutual agreement following
of unsatisfactory performance
charges or allegations of misconduct
4 – Quit job after being told you’d be fired

5 – Fired from job
6 – Laid off from job by employer
7 – Other (explain)

13A Employment Information
(#1) Dates of Employment

Type of Employment

Month/Year

 Federal  Military/Federal
Contractor
 Military
 State Government

To

Month/Year

Present

Employer/Verifier

Name of employer/verifier

 Unemployment
 Self-employment
 Other

Telephone number
(

Address of employer/verifier

)

Position title/Military rank
Work hours

 Full-time  Part-time

Supervisor

Name and title (last, first)
Address of supervisor

City (Country), State, and Zip Code

Telephone number
(

)

City (Country), State, and Zip Code

Physical Location

Your physical location (if different from employer address)

Telephone number
(
)

City (Country), State, and Zip Code

Additional Periods of Activity with this Employer
Month/Year

To

Month/Year

Position Title

Supervisor

Explanation/Reason for leaving

Reason for leaving code (if applicable)

(#2) Dates of Employment

Type of Employment

Month/Year

 Federal  Military/Federal
Contractor
 Military
 State Government

To

Month/Year

Employer/Verifier

Name of employer/verifier

 Unemployment
 Self-employment
 Other

Telephone number
(

Address of employer/verifier

)

Position title/Military rank
Work hours

 Full-time  Part-time

Supervisor

Name and title (last, first)
Address of supervisor

City (Country), State, and Zip Code

City (Country), State, and Zip Code

Physical Location

Your physical location (if different from employer address)

Telephone number
(
)

City (Country), State, and Zip Code

Additional Periods of Activity with this Employer
Month/Year

To

Month/Year

Position Title

Supervisor

Explanation/Reason for leaving

Reason for leaving code (if applicable)

Enter your Social Security Number before going to the next page
Page 4

Telephone number
(

)

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

13 EMPLOYMENT ACTIVITIES (Continued)
(#3) Dates of Employment

Type of Employment

Month/Year

 Federal  Military/Federal
Contractor
 Military
 State Government

To

Month/Year

Employer/Verifier

Name of employer/verifier

 Unemployment
 Self-employment
 Other

Telephone number
(
)

Address of employer/verifier
City (Country), State, and Zip Code

Telephone number
(
)

Your physical location (if different from employer address)

Additional Periods of Activity with this Employer
To

Month/Year

Work hours

 Full-time  Part-time

Supervisor

Name and title (last, first)
Address of supervisor

Telephone number
(

)

City (Country), State, and Zip Code

Physical Location

Month/Year

Position title/Military rank

Position Title

Supervisor

City (Country), State, and Zip Code

Explanation/Reason for leaving

Reason for leaving code (if applicable)

(#4) Dates of Employment

Type of Employment

Month/Year

 Federal  Military/Federal
Contractor
 Military
 State Government

To

Month/Year

 Unemployment
 Self-employment
 Other

Employer/Verifier

Position title/Military rank
Work hours

 Full-time  Part-time

Supervisor
Telephone number

Name of employer/verifier

(

Name and title (last, first)

)

Address of employer/verifier

Address of supervisor

City (Country), State, and Zip Code

City (Country), State, and Zip Code

Telephone number
(

)

Physical Location
Your physical location (if different from employer address)

Additional Periods of Activity with this Employer
Month/Year

To

Month/Year

Position Title

Telephone number
(

City (Country), State, and Zip Code

)
Supervisor

Explanation/Reason for leaving

Reason for leaving code (if applicable)

13B List any former Federal service, excluding Military service, if not indicated previously.
Dates of Federal Service

Month/Year

To

Month/Year

Agency/City (Country)/State/Zip Code

Position Title

#1
#2
#3

13C Have any of the following happened to you in the last 7 years?
Have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace?
a
Have you received a written warning, been officially reprimanded, suspended, or disciplined for violating a security rule or policy?
b

YES

NO

If you answered “Yes,” to 13C(a) and/or 13C(b), provide the name of employer(s), date of incident, month/year of official action, location or facility of incident,
and the nature of the violation in the space below. If additional space is needed, use a blank sheet of paper.

Enter your Social Security Number before going to the next page
Page 5

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

14 PEOPLE WHO KNOW YOU WELL
List three people who know you well and preferably who live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc., who
are aware of your activities outside of the workplace, school, or neighborhoods and whose combined association with you covers at least the last 7 years. Do
not list your spouse, former spouse(s), other relatives, or anyone listed elsewhere on this form.
Reference name (last, first)

Dates known

#1

Month/Year

Home or work address

To

Month/Year

Relationship to you

Telephone number

 Neighbor

 Work Associate  Other

Day (

)

 Schoolmate
State

Night (

)

 Friend
City (Country)

Apt. #

ZIP Code

Alternate telephone number

(
Reference name (last, first)

Dates known

#2

Month/Year

Home or work address

To

Month/Year

Telephone number

 Neighbor

 Work Associate  Other

Day (

)

 Schoolmate
State

Night (

)

 Friend
City (Country)

Apt. #

ZIP Code

Alternate telephone number

(
Reference name (last, first)

Dates known

#3

Month/Year

Home or work address

To

Month/Year

Apt. #

)

Relationship to you

)

Relationship to you

Telephone number

 Neighbor

 Work Associate  Other

Day (

)

 Schoolmate
State

Night (

)

 Friend
City (Country)

ZIP Code

Alternate telephone number

(

)

15 MARITAL STATUS
Mark one box to show your current marital status and provide information about your spouse below.
 1 – Never married

 3 – Separated

 5 – Annulled

 2 – Married (incl. Common Law)

 4 – Divorced

 6 – Widowed

CURRENT SPOUSE Complete the following about your current spouse only. If born outside the U.S., provide citizenship information.
Full name (last, first, middle)

Date of birth

Place of birth (include country if outside the U.S.)

Social Security Number
Country(ies) of Citizenship

Other names used (Specify maiden name, names by other marriages, etc., and show dates used for each name)
Date married

Place married (include country if outside the U.S.)

State

ZIP Code

If separated, date of separation

If legally separated, where is the record located? City (Country)

State

ZIP Code

State

ZIP Code

Current address of spouse, if different than your current address (Street, city, and country if outside the U.S.)

Telephone number
(

)

If spouse was born outside the U.S., check the appropriate box and provide document number.
 State Department Form 240

 U.S. Passport (current or most recent)

 Naturalization Certificate

 Citizenship Certificate

 Alien Registration

 Other

Enter your Social Security Number before going to the next page
Page 6

Document Number_____________________

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

16 RELATIVES
Give the full name, correct code, and other requested information for each of your relatives, living or dead, specified below.
1 – Mother
3 – Stepmother
5 – Foster Parent
7 – Stepchild
2 – Father
4 – Stepfather
6 – Child (incl. adopted and foster)
Full name
(last, first, middle)
(if deceased,
check box)

Relative
code
(1-7)

Date of birth
(mm/dd/yyyy)

Country of birth

Country(ies) of Citizenship



1


2














Enter your Social Security Number before going to the next page
Page 7

Current street address,
City, State, Zip Code,
and country of living relatives

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

16 RELATIVES (Continued)
Give the full name, correct code, and other requested information for each of your relatives, living or dead, specified below.
5 – Foster Parent
3 – Stepmother
7 – Stepchild
1 – Mother
4 – Stepfather
6 – Child (incl. adopted and foster)
2 – Father
Full name
(last, first, middle)
(if deceased,
check box)

Relative
Code
(1-7)

Date of birth
(mm/dd/yyyy)

Country of birth

Current street address,
City, State, Zip Code,
and Country of living relatives

Country(ies) of Citizenship







17 MILITARY HISTORY
Account for all of your military service through the questions below.
a
Have you EVER served in the U.S. Military, the U.S. Merchant Marine, or the commissioned corps of the U.S. Public Health
Service (PHS) or National Oceanic and Atmospheric Administration (NOAA)?
Have you EVER served in the military, security forces, merchant marine, militia, or other defense forces of any foreign country?
b
Have you EVER received other than an honorable discharge? If "Yes," explain.
c

d

•
•

YES

NO

Have you EVER been subject to an Article 15 or been charged with any violation of the Uniform Code of Military Justice?
If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and outcome(s).

If you answered "No" to questions 17a –17d above, proceed to question #18.

If you answered "Yes" to any question above, list all details of your military service below, starting with the most recent period of service and working

back. If you had a break in service, each separate time of service should be listed.


Code (Branch of Service): Use one of the codes listed below to identify your branch of service.
5 – Coast Guard
7 – National Guard
9 – NOAA
1 – Air Force 3 – Navy
8 – PHS
6 – Merchant Marine
2 – Army
4 – Marine Corps
10 – Foreign military, defense, militia, security forces






O/E: Mark "O" block for Officer or "E" block for Enlisted, if applicable.
Status: "X" the appropriate block for the status of your service during the time that you served.
Country: If your service was with other than the U.S. Armed Forces, identify the country for which you served.
Code (Type of Discharge): Use one of the codes listed below to indicate your separation status from your military service.
1 – Honorable

Branch of
Month/Year
Service Code

To

2 – Dishonorable
Month/Year

Service/
Certificate Number

3 – Hardship

O

E

5 – Other (explain)

4 – Medical

Status
Active Active Inactive
Duty Reserve Reserve

National
Guard
State
State

Enter your Social Security Number before going to the next page

Page 8

Country

Type of
Discharge Code

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

18 SELECTIVE SERVICE RECORD
Are you a male born after December 31, 1959? If “No,” go to question #19. If “Yes,” go to b.
a
Have you registered with the Selective Service System? If “Yes,” provide your registration number. If “No,” explain the reason for not
b

registering.
Registration Number

NO

YES

Explanation

19 INVESTIGATIONS RECORD
a Has the United States Government or a foreign government EVER investigated your background and/or granted you a security clearance? If

YES

“Yes,” use the codes that follow to provide the requested information below. If “Yes,” but you can’t recall the investigating agency and/or the
security clearance received, enter “Other” agency code or clearance code, as appropriate, and “Don’t know” or “Don’t recall” under the “Other
Agency” heading below. If your response is “No,” or you don’t know or can’t recall if you were investigated and cleared, check the “No” box.
Codes for Investigating Agency
Codes for Security Clearance Received
4 – Federal Bureau of Investigation
5 – Sensitive Compartmented
8 – Issued by foreign
1 – Not Required
1 – Defense Department
5 – Treasury Department
2 – Confidential
Information
country
2 – State Department
6 – Department of Homeland Security
3 – Secret
6–Q
9 – Other
3 – Office of Personnel
Management
7 – Other (Specify)
4 – Top Secret
7–L

Month/Year

Agency
Code

Clearance
Code

Other Agency

Month/Year

#1

#3

#2

#4

b

Agency
Code

Other Agency

Have you EVER had a clearance or access authorization denied, suspended, or revoked; received a Statement of Reasons from an adjudicative
facility; or been debarred from government employment? If “Yes,” give date of action, agency, and circumstances.

Month/Year

Department or Agency Taking Action

NO

Clearance
Code

YES

NO

YES

NO

Circumstances

#1
#2

c

In the last 7 years, have you applied or been nominated for a position requiring a security clearance, and later withdrew from the process prior
to the conclusion of the investigation? If “Yes,” provide the agency, position, date of application, and reason for withdrawal.

Date of Application

Agency

Position

Reason for Withdrawal

#1
#2

20 FOREIGN COUNTRIES YOU HAVE VISITED
List foreign countries you have visited in the past 7 years, beginning with the most current and working back. If you have lived near a border and have made
short (one day or less) trips to the neighboring country (i.e. Canada or Mexico), you do not need to list each trip. Instead, provide the time period, the code,
the country, and a note (“Many Short Trips”).

Use these codes to indicate the purpose(s)
1 – Business/ Professional Conference
3 – Volunteer Activities
5 – Visit Family or Friends
of your visit:
2 – Education
4 – Tourism
6 – Other
Code

Month/Year To

Month/Year

Number
of Days

Country

Code

#1

#3

#2

#4

Enter your Social Security Number before going to the next page
Page 9

Month/Year

To

Month/Year

Number
of Days

Country

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

21 POLICE RECORD
a
b
c
d

YES

NO

In the last 7 years, have you been arrested for, charged with, or convicted of any offense(s)? (Omit traffic fines of less than $300.)
In the last 7 years, have you been imprisoned, on probation, or on parole?
Are you now under charges for any violation of the law?
In the last 7 years, have you been convicted by a military court martial? (If no military service, answer “No”.)

If you answered “Yes” to any question above, explain below, providing information for each and every offense. Enter “N/A” for any fields that do not apply.
Month/Year

Offense

Law Enforcement
Authority/Court

Disposition

City and Country if
Outside U.S.

State

ZIP Code

#1
#2
#3

22 USE OF ILLEGAL DRUGS AND DRUG ACTIVITY
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully,
and your failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor
information derived from your responses will be used as evidence against you in any subsequent criminal proceeding.
In the last year, have you illegally used any controlled substance, for example, cocaine, crack cocaine, THC (marijuana, hashish,
a
etc.), narcotics (opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed, crystal methamphetamine, Ecstasy,
ketamine, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants
(toluene, amyl nitrate, etc.) or prescription drugs (including painkillers)?
In the last 7 years, have you been involved in the illegal possession, purchase, manufacture, trafficking, production, transfer, shipping,
b
receiving, handling, or sale of any controlled substance (see question a above) including prescription drugs?

YES

NO

If you answered “Yes” to any question above (a-b), provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity.
Dates of Use/Activity
Month/Year
To
Month/Year

Type of Controlled Substance(s)

Explain nature of use/actvity, frequency of activity, and number of times used

#1
#2

23 FINANCIAL RECORD
a In the last 7 years, have you, or a company over which you exercised some control, filed for bankruptcy, been declared bankrupt,

YES

NO

been subject to a tax lien, or had legal judgment rendered against you for a debt? If you answered “Yes,” provide date of initial action
and other information requested below.

Month/Year

Type of Action

Name Action
Occured Under

Name/Address of Court or Agency Handling Case

State

ZIP Code

#1
#2

b

Are you now over 180 days delinquent on any debt? Disclose all financial obligations that apply, including those for which you are a
cosigner or guarantor.

YES

NO

If you answered “Yes,” provide the information requested below.
Month/Year

Type of Loan or Obligation
and Account Number

Name/Address of Creditor or Obligee

State

ZIP Code

#1
#2

Certification

My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are
made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both
(18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information will have a negative effect on my
employment prospects or job status, up to and including my removal and debarment from Federal service.
Signature (Sign in Ink)

Enter your Social Security Number before going to the next page
Page 10

Date (mm/dd/yyyy)

Standard Form 85P
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Form approved:
OMB No. 3206 0005
NSN 7540-01-317-7372
86-111

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date it in ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal
agency conducting my background investigation, to obtain any information relating to my activities from
individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus,
consumer reporting agencies, collection agencies, retail business establishments, or other sources of information.
This information may include, but is not limited to, my academic, residential, achievement, performance,
attendance, disciplinary, employment history, and criminal history record information, and financial and credit
information. I authorize the Federal agency conducting my investigation to disclose the record of my background
investigation to the requesting agency for the purpose of making a determination of suitability for a public trust
position.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals,
and other sources of information, separate specific releases may be needed and I may be contacted for such
releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office of Personnel
Management, the Federal Bureau of Investigation, the Department of Defense, the Department of State, and any
other authorized Federal agency, to request criminal record information about me from criminal justice agencies
for the purpose of determining my eligibility for assignment to, or retention in, a public trust position, in
accordance with 5 U.S.C. 9101. I understand that I may request a copy of such records as may be available to
me under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of any Federal agency
authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by
the Federal Government only for the purposes provided in this Standard Form 85P, and that it may be disclosed
by the Government only as authorized by law.
Copies of this authorization that show my signature are valid. This authorization is valid for five (5) years from the
date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)

Full name (Type or print legibly)

Date signed (mm/dd/yyyy)

Other names used

Street address

Social Security Number

Apt. #

City (Country)

State

Zip Code

Home telephone number
(

)