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pdfForm approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Questionnaire for National Security 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
Special Instructions for Completing this Form
The United States Government conducts background investigations and
reinvestigations of persons under consideration for or retention in national security
positions as defined in 5 CFR 732 and for positions requiring access to classified
information under Executive Order 12968.
Some questions on this form specify a time frame of seven (7) years or ten (10) years,
depending on what type of investigation is required. When a Single-Scope
Background Investigation (SSBI) is required, some of the items on this form will
require a 10 year time frame.
Giving us this information is voluntary. However, if you do not provide us each item of
requested information, we will not be able to complete your investigation, which will
adversely affect your eligibility for a national security position. 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.
The instructions for these questions specify a 10-year time frame when an SSBI is
required. If you have any questions about whether the 7-year time frame or the 10year time frame applies to your responses to these questions, contact the office that
gave you this form.
Withholding, misrepresenting, or falsifying information will have an impact on a security
clearance, employment prospects, or job status, up to and including denial or
revocation of your security clearance, or your removal and debarment from Federal
Service.
Instructions for Completing this Form
This form is a permanent document that may be used as the basis for future
investigations, security clearance determinations, and determinations of your suitability
for employment. Your responses to this form may be compared with previous security
questionnaires. Therefore, it is imperative that the information provided be true and
accurate to the best of your knowledge.
1. 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 ink, the original and each copy you submit. You should retain a
copy of the completed form for your records.
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.
2. Type or legibly print your answers in ink (if the 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 an electronic
version of this form.
Authority to Request this Information
3. All questions on this form must be answered. If no response is necessary or
applicable, indicate this on the form with “N/A”.
Depending upon the purpose of your investigation, the United States Government is
authorized to ask for this information under Executive Orders 10450, 10865, 12333,
12356, and 12968; sections 3301, 3302, and 9101 of title 5, United States Code;
sections 2165 and 2201 of title 42, United States Code; chapter 23 of title 50, United
States Code; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal Regulations.
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.
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.
6. Whenever “City (Country)” is shown in an address block, also provide in that block
the name of the country when the address is outside the United States.
The Investigative Process
Background investigations for national security 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.
In addition to the questions on this form, inquiry also is made about a person's
adherence to security requirements, honesty and integrity, vulnerability to exploitation
or coercion, falsification, misrepresentation, and any other behavior, activities, or
associations that tend to show the person is not reliable, trustworthy, or loyal. Checks
of Federal Agency records may be made about your spouse or other cohabitant.
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 as well. 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.
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.
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/
self-employment/unemployment, or education, you should use a continuation
sheet, SF 86A. If additional space is needed to answer other items, use a blank
sheet of paper. Each blank sheet 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 national security 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, do not grant a
security clearance, or disqualify individuals who have materially and deliberately
falsified these forms, and this remains a part of the permanent record for future
placements. Because the position for which you are being considered is a sensitive
one, your trustworthiness is a very important consideration in deciding your eligibility.
Your prospects of placement or security clearance are better if you answer all
questions truthfully and completely. You will have adequate opportunity to explain any
information you give us on this form and to make your comments part of the record.
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Disclosure of Information
The information you give us is for the purpose of investigating you for a national security position; 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.
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 86. 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.
•
•
•
•
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
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.
(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.
To disclose information to contractors, grantees, experts, consultants or volunteers performing or
working on a contract, service, or job for the Federal Government.
STATE CODES
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
American Samoa
Palau
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
AS
PW
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
Federated States of Micronesia FM
Puerto Rico
PR
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 120 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 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY 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 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
10 CITIZENSHIP INFORMATION
YES NO
Do you now hold or have you ever held multiple citizenships?
(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 10 years (if not an SSBI go 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
Street address
Status
Own
Rent
Point of Contact for that Period of Residence
Name of person who knows you (last, first)
Military Housing
Other
Apt. #
APO/FPO address
#2
(
APO/FPO address (if currently applicable)
City (Country)
Month/Year
Current address
Relationship
Landlord
Neighbor
Business Associate
Friend
Other
Apt. #
Telephone number
State
To
Month/Year
Street address
Status
Own
Rent
Zip Code
City (Country)
State
Name of person who knows you (last, first)
Military Housing
Other
Apt. #
Current address
Zip Code
)
Alternate contact number
(
Relationship
Neighbor
Friend
Apt. #
)
Landlord
Business Associate
Other
Telephone number
(
APO/FPO address
City (Country)
Month/Year
)
APO/FPO address (if currently applicable)
State
To
Month/Year
#3
Street address
Status
Own
Rent
Zip Code
City (Country)
State
Zip Code
Alternate contact number
(
Name of person who knows you (last, first)
Military Housing
Other
Apt. #
Current address
Relationship
Neighbor
Friend
Apt. #
)
Landlord
Business Associate
Other
Telephone number
(
APO/FPO address
City (Country)
Month/Year
#4
Street 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
Zip Code
Alternate contact number
(
)
Relationship
Landlord
Neighbor
Business Associate
Friend
Other
Apt. #
Telephone number
(
APO/FPO address (if currently applicable)
APO/FPO address
City (Country)
State
Zip Code
City (Country)
State
Zip Code
Enter your Social Security Number before going to the next page
)
Alternate contact number
(
Page 2
)
APO/FPO address (if currently applicable)
)
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
12 WHERE YOU WENT TO SCHOOL
List the schools you have attended, beginning with the most recent (#1) and working back 10 years (if not an SSBI go back 7 years). List college or university
degrees and the dates they were received. If all of your education occurred more than 10 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 10 years, list a person who knew you at school (instructor, student, etc.).
Do not list people for education completely outside this 10-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 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
13 EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 10 years (if not an SSBI go back 7 years). You should list all full-time and parttime 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
)
Your physical location (if different from employer address)
Additional Periods of Activity with this Employer
Month/Year
Full-time Part-time
Name and title (last, first)
Telephone number
(
)
City (Country), State, and Zip Code
Physical Location
To
Work hours
Supervisor
Address of supervisor
City (Country), State, and Zip Code
Month/Year
Position title/Military rank
Telephone number
(
Position Title
City (Country), State, and Zip Code
)
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
City (Country), State, and Zip Code
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
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 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY 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
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
Telephone number
(
)
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
Military
Contractor
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
Your physical location (if different from employer address)
Additional Periods of Activity with this Employer
To
Month/Year
Work hours
Supervisor
Full-time Part-time
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
Telephone number
(
)
Supervisor
City (Country), State, and Zip Code
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 86
Revised April 2006
U.S. Office of Personnel Management
CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
14 SELECTIVE SERVICE RECORD
a Are you a male born after December 31, 1959? If "No," go to question #15. If "Yes," go to b.
b Have you registered with the Selective Service System? If "Yes," provide your registration number. If "No," explain the reason for
YES
NO
not registering.
Registration Number
Explanation
15 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)?
b Have you EVER served in the military, security forces, merchant marine, militia, or other defense forces of any foreign country?
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 15a –15d above, proceed to question #16.
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
3 – Hardship
2 – Dishonorable
Month/Year
Service/
Certificate Number
O
E
5 – Other (explain)
4 – Medical
Status
Active Active Inactive
Duty Reserve Reserve
Type of
Discharge Code
Country
National
Guard
State
State
16 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)
#1
Home or work address
Dates known
Month/Year To Month/Year
Apt. #
Relationship to you
Telephone number
Neighbor Work Associate Other
Friend
Schoolmate
Day (
)
Night (
)
City (Country)
State
ZIP Code
Alternate telephone number
(
Reference name (last, first)
#2
Home or work address
Dates known
Month/Year To Month/Year
Apt. #
)
Relationship to you
Telephone number
Neighbor Work Associate Other
Friend
Schoolmate
Day (
)
Night (
)
City (Country)
State
ZIP Code
Alternate telephone number
(
Reference name (last, first)
#3
Home or work address
Dates known
Month/Year To Month/Year
Apt. #
Neighbor Work Associate Other
Friend
Schoolmate
City (Country)
State
ZIP Code
Day (
)
Night (
)
Alternate telephone number
(
Enter your Social Security Number before going to the next page
Page 6
)
Telephone number
Relationship to you
)
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
17 MARITAL STATUS
Mark one box to show your current marital status and provide information about your spouse(s) or cohabitant below.
1 – Never married
3 – Separated
5 – Annulled
2 – Married (incl. Common Law)
4 – Divorced
6 – Widowed
17A 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
Document Number_____________________
17B FORMER SPOUSE(S) Complete the following about your former spouse(s). Use blank sheets if needed.
Full name (last, first, middle)
Date of birth
Place of birth (include country if outside the U.S.)
State
ZIP Code
Country(ies) of Citizenship
Date married
Place married (include country if outside the U.S.)
State
ZIP Code
Check one, then give date
Month/Year
If divorced/annulled, where is the record located? City (Country)
State
ZIP Code
Divorced
Widowed Annulled
Last known address of former spouse (Street, City, and Country if outside the U.S.)
State
ZIP Code
Telephone number
(
)
17C COHABITANT (A cohabitant is a person with whom you live in a spouse–like relationship and share bonds of affection, obligation or other commitments.)
Complete the following about your cohabitant. 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
Other names used (specify maiden name, names by other marriages, etc., and show dates used for each name)
Country(ies) of Citizenship
Date cohabitation began
If cohabitant 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
Document Number_____________________
18 RELATIVES
Relative Code – Use one of the following codes (1-16) listed below for each relative and give the full name and other requested information for each of your relatives
and associates, living or deceased, specified below.
1 – Mother
5 – Foster parent
9 – Sister
13 – Half-sister
2 – Father
6 – Child (incl. adopted and foster)
10 – Stepbrother
14 – Father-in-law
3 – Stepmother
7 – Stepchild
11 – Stepsister
15 – Mother-in-law
4 – Stepfather
8 – Brother
12 – Half-brother
16 – Guardian
Citizenship Code – Use one of codes below (a-e) listed below to show the citizenship status of each relative listed. If you select codes b, c, d, or e, provide
citizenship information below.
a – U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth
b – U.S. citizen by birth, born outside the U.S.
c – Naturalized U.S. citizen
d – Not a U.S. citizen
Citizenship Information – Use one of the following codes (1-6) to show citizenship information of each relative listed.
1 – Naturalization Certificate
3 – State Department Form 240
5 – Alien Registration
2 – Citizenship Certificate
4 – U.S. Passport (current or most recent)
6 – Other
Enter your Social Security Number before going to the next page
Page 7
e – Other
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
18 RELATIVES (Continued)
Relative
Code
(1-16)
Full Name
(last, first, middle)
(if deceased,
check box)
Date of Birth
(mm/dd/yyyy)
Country(ies) of
Citizenship
Country
of Birth
Citizenship
Code
(a-e)
Citizenship
Information
Code (1-6)
(if applicable)
Current Street Address,
City, State, Zip Code,
and Country of Living Relatives
1
Document Number
2
Document Number
Document Number
Document Number
Document Number
Document Number
Document Number
19 FOREIGN CONTACTS
This section asks about your contact with foreign nationals within the past 7 years. List any and all foreign nationals with whom you have had close and/or
continuing contact, including associates, as well as relatives not required to be recorded in section 18.
Provide the full name and country of citizenship of the foreign contact and your dates of association. Indicate the nature and extent of your contact with the
individual by marking the appropriate box. If you are or were stationed abroad or have had duties that require contact with foreign nationals, list only those foreign
nationals with whom you have a close and/or continuing personal/business/professional relationship.
Full Name
(last, first, middle)
Dates Known
Month/Year
To Month/Year
Approximate
Current Age
Country(ies) of Citizenship
#1
#2
#3
Enter your Social Security Number before going to the next page
Page 8
Type of
Contact
Nature of
Relationship
Business
Personal
Other
Business
Personal
Other
Business
Personal
Other
Telephone
Telephone
Telephone
Electronic Correspondence
Written Correspondence
In Person
Number of
Contacts per
year
1-2
1-2
1-2
3-7
8-15
More than 15
Other
Electronic Correspondence
Written Correspondence
In Person
3-7
8-15
More than 15
Other
Electronic Correspondence
Written Correspondence
In Person
Other
3-7
8-15
More than 15
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
20 FOREIGN ACTIVITIES
For the following questions, respond for the timeframe of the past 7 years.
20A Foreign Financial Interests
Do you have or have you had any foreign financial interests of which you have direct control or direct ownership?
1.
Purpose
YES
NO
YES
NO
Amount of Funds in U.S. Dollars
2.
Do you have or have you had any foreign financial interests that someone controls on your behalf?
Purpose
Amount of Funds in U.S. Dollars
3.
Do you own or have you owned real estate in a foreign country?
Type of Property
Location of Property
Estimated Value of Property in U.S. Dollars
20B Foreign Business, Professional Activities, and Foreign Government Contacts
1. Have you provided advice or support regarding any of the following: management, strategy, financing, or development and/or use of
technology to any foreign national associated with a foreign business or other foreign organization that you have not previously listed as a
former employer?
If “Yes” AND the activity was outside of official U.S. Government business, describe advice/support provided, name of foreign national
and/or organization(s) to which it was provided, the name(s) of foreign country(ies), timeframe, and if compensation was provided.
2.
Have you attended two or more international conferences, trade shows, seminars, or other meetings outside of the U.S.?
If “Yes” AND the activity was outside of official U.S. Government business, provide locations, including the name(s) of foreign country(ies),
dates, sponsoring organization(s), and purpose of events(s).
3.
Have you been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency?
If “Yes” AND the activity was outside of official U.S. Government business, provide the date of consultation, including the name(s) of
foreign country(ies), location of consultation, and circumstances.
4.
Have you had any contact with a foreign government, its establishment (embassies or consulates), or its representatives, whether inside
or outside the U.S.?
If “Yes” AND the activity was outside of official U.S. Government business, provide the date of contact(s), location of contact(s), including the
name(s) of foreign country(ies), and circumstance(s) of contact(s).
5.
Have you sponsored any foreign citizen to come to the U.S. as a student, for work, or for permanent residence?
If “Yes,” provide the name of the foreign citizen(s) you sponsored, the country(ies) of citizenship, the date of the foreign citizen’s stay in the
U.S., their current address (if known), and the purpose of the foreign citizen’s stay in the U.S.
6.
20C
Have you held or do you hold a passport that was issued by a foreign government?
If “Yes,” provide the name in which your foreign passport(s) was issued, the issuing country, the passport number, the issue date, and the
expiration date.
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 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
21 MENTAL AND EMOTIONAL HEALTH
YES
NO
In the last 7 years, have you received counseling or treatment from a mental health professional (including a counselor, licensed
social worker, psychologist, psychiatrist, or other psychotherapist) or any other medical professional regarding an emotional or
mental condition? Answer “No” if the counseling was strictly marital, family, or grief counseling and did not involve the prescription of
medication or violence by you.
If you answered “Yes,” indicate who conducted the treatment, provide the following information, and sign the Authorization for Release of Medical Information Pursuant
to the Health Insurance Portability and Accountability Act (HIPAA).
Dates of Treatment
Month/Year
To
Month/Year
Name/Address/Zip Code of Provider
Explain Circumstances of Treatment
#1
#2
22 POLICE RECORD
a
b
c
d
e
For this item, report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record. You need
not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18
U.S.C. 3607.
Be sure to include all incidents whether occurring in the U.S. or abroad.
Answer questions a & b for the past 10 years (if not an SSBI go back 7 years) excluding any fines of less than $300 for traffic offenses
YES
NO
that do not involve alcohol or drugs.
Have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you; are you on trial or
awaiting a trial on criminal charges; or are you currently awaiting sentencing for a criminal offense?
Have you been detained or arrested by any police officer, sheriff, marshal, or any other type of law enforcement officer?
Have you EVER been charged with any felony offense? (Include those under Uniform Code of Military Justice.)
Have you EVER been charged with a firearms or explosives offense?
Have you EVER been charged with any offense(s) related to alcohol or drugs?
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
Disposition
Law Enforcement
Authority/Court
City and Country if
Outside U.S.
State
ZIP Code
#1
#2
#3
23 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 7 years, have you illegally used any controlled substance, for example, cocaine, crack cocaine, THC (marijuana, hashish, etc.),
a
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)? Illegal use of a controlled substance includes injecting, snorting, inhaling,
swallowing, experimenting with or otherwise consuming any controlled substance.
b
c
YES
NO
Have you EVER illegally used a controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official;
while possessing a security clearance; or while in a position directly and immediately affecting the public safety?
In the last 7 years, have you been involved in the illegal possession, purchase, manufacture, trafficking, production, transfer, shipping,
receiving, handling, or sale of any controlled substance (see question a above) including prescription drugs?
If you answered “Yes” to any question above (a-c), 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/activity, frequency of activity and number of times used
#1
#2
Enter your Social Security Number before going to the next page
Page 10
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
24 USE OF ALCOHOL
YES
For the following questions, respond for the time frame of the past 7 years.
NO
a Has your use of alcohol had a negative impact on your work performance, your professional or personal relationships, or your finances, or
resulted in contacts by law enforcement/public safety personnel? (If “Yes,” explain.)
b Have you received counseling or treatment or have you been ordered, advised, or asked to seek counseling or treatment as a result of your
use of alcohol?
If you answered “Yes” to question b above, provide the dates of treatment and the name and address of the counselor or doctor below. Do not repeat information
reported in response to item 21. You will be asked to sign a release if information is needed concerning your treatment.
Month/Year
To
Name/Address/Zip Code of Counselor or Doctor
Month/Year
#1
#2
25 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
#1
#2
Enter your Social Security Number before going to the next page
Page 11
Reason for Withdrawal
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
26
a
b
c
d
e
f
g
h
i
j
k
l
m
n
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
FINANCIAL RECORD
YES
For the following, answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including
those for which you are a cosigner or guarantor.
Have you filed a petition under any chapter of the bankruptcy code?
NO
Have you had any possessions or property voluntarily or involuntarily repossessed or foreclosed?
Have you failed to pay Federal, state, or other taxes, or to file a tax return, when required by law or ordinance?
Have you had a lien placed against your property for failing to pay taxes or other debts?
Have you had a judgment entered against you?
Have you defaulted on any type of loan?
Have you had bills or debts turned over to a collection agency?
Have you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed?
Have you been evicted for non-payment of financial obligations?
Have you been delinquent on court-imposed alimony or child support payments?
Have you had your wages, benefits, or assets garnished or attached for any reason?
Have you violated the terms of agreement for a travel or credit card provided by your employer?
Have you been over 180 days delinquent on any debt(s)?
Are you currently over 90 days delinquent on any debt(s)?
If you answered “Yes” to any question above (a-n), provide the information requested below for each positive response, indicating the corresponding question letter.
Question
(a-n)
Amount or Property
Value Involved
Month/Year
Account Number
Name of Agency/Organization/Individual to Whom Debt is Owed
#1
Name/Address/Zip Code of Court or Agency Handling Case
Question
(a-n)
Amount or Property
Value Involved
Month/Year
Name Action/Debt is Recorded Under
Account Number
Status of Action or Debt
Name of Agency/Organization/Individual to Whom Debt is Owed
#2
Name/Address/Zip Code of Court or Agency Handling Case
Name Action/Debt is Recorded Under
Status of Action or Debt
27 USE OF INFORMATION SYSTEMS
a
b
c
The following questions ask about your use of information technology systems, which include all types of stand-alone computer
systems, networked systems, the Internet, and telecommunication devices such as telephones, cell phones, and fax machines.
In the last 7 years, have you illegally or without proper authorization entered into any information technology system?
In the last 7 years, have you illegally or without proper authorization modified, destroyed, manipulated, or denied others access to
information residing on an information technology system?
In the last 7 years, have you introduced, removed, or used hardware, software, or media in connection with any information technology
system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations?
YES
NO
If you answered “Yes” to any question above (a-c), provide the following information requested for each incident.
#1
Date of Incident
(Mo./Yr.)
Nature of Incident/Offense
Location Incident Took Place
Disposition
#2
28 INVOLVEMENT IN NON-CRIMINAL COURT ACTIONS
YES
NO
In the last 10 years, have you been a party to any public record civil court actions not listed elsewhere on this form?
If you answered “Yes,” provide the information about each public record civil court action requested below.
Month/Year
Nature of Action
Result of Action
Name of Parties Involved
#1
#2
Enter your Social Security Number before going to the next page
Page 12
Court Name, Address
and Zip Code
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
29 ASSOCIATION RECORD
Have you EVER been an officer or a member or made a contribution to an organization dedicated to terrorism or the violent overthrow
a
b
c
YES
NO
of the United States Government and which engaged in illegal activities to that end, knowing that the organization engaged in such
activities with the specific intent to further such activities?
Have you EVER advocated or engaged in any acts of terrorism or any acts or activities designed to overthrow the United States
Government by force?
Have you EVER participated in militias (not including official state government militias) or paramilitary groups?
If you answered “Yes” to any of the questions above, explain in the space provided.
CONTINUATION SPACE
Use the space below to continue answers to all other items and to provide any information you would like to add. If more space is needed than is provided
below, use a blank sheet(s) of paper. Start each sheet with your name and SSN. Before each answer, identify the number of the item.
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and
accurate, and then sign and date the following certification and the attached release.
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
security clearance, employment prospects, or job status, up to and including denial or revocation of my security clearance, or my removal
and debarment from Federal service.
Signature (Sign in Ink)
Enter your Social Security Number before going to the next page
Page 13
Date (mm/dd/yyyy)
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY 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, 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 or eligibility for a
national security 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 national security 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 86, 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. Read,
sign and date the release on the next page if you answered “Yes” to question 21.
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
(
)
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised April 2006
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00-634-4036
86-111
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Carefully read this authorization to release information about you, then sign and date it in ink.
Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) the three questions below concerning your
mental health consultations. Your signature will allow the practitioner(s) to answer only these questions.
Authorization
I am seeking assignment to or retention in a national security position. As part of the clearance process, I
hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal
agency conducting my background investigation, to obtain the following information relating to my mental health
consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to
the Office of Personnel Management (OPM). I understand that I may revoke this authorization except to the
extent that action has already been taken based on this authorization. Further, I understand that this
authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not
be conditioned upon my authorization of this disclosure.
I understand the information disclosed pursuant to this release is for use by the Federal Government only for
purposes provided in the Standard Form 86 and that it may be disclosed by the Government only as authorized
by law, but will no longer be subject to the HIPAA privacy rule.
Copies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date
signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)
Date signed (mm/dd/yyyy)
Full name (Type or print legibly)
Social Security Number
Other names used
Street address Apt. #
City (Country)
State
Zip Code
Home telephone number
(
)
For Use By Practitioner(s) Only
Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability
to properly safeguard classified national security information?
YES
NO
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
Signature (Sign in ink)
Practitioner name
Date signed (mm/dd/yyyy)
| File Type | application/pdf |
| File Modified | 2006-05-08 |
| File Created | 2005-09-10 |