Download:
pdf |
pdfForm Completion Instructions · Instructions for Completing Form SF86
Help · Display · Logout
Page 1 of 6
Navigation: Select Investigation Request
Form Completion Instructions
Instructions for Completing Form SF86
Go
OMB No. 3206-0005
Form: SF86
Public Burden Information
At the end of these instructions, you must certify that you have carefully read the
instructions before you will be allowed to begin this form.
Questionnaire for National Security Positions (SF86 Format)
OMB No. 3206-0005
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
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.
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.
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.
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.
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.
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 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.
Your Social Security Number (SSN) is needed to keep records accurate because other people may
Form Completion Instructions · Instructions for Completing Form SF86
Page 2 of 6
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 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.
Special Instructions for Completing this Form
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.
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 10- year time frame applies to your
responses to these questions, contact the office that gave you this form.
Form Completion Instructions · Instructions for Completing Form SF86
Page 3 of 6
Instructions for Completing this Form
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. You should retain a copy
of the completed form for your records.
2. All questions on this form must be answered. If no response is necessary or applicable, indicate
this on the form by checking the associated "Not Applicable" box.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a
country name, you may select the country name by using the country list feature.
To use the country list feature, click on the "List" link beside the "Country" title to open a listing of
country names in a separate window. Find the desired country name and use your web browser's
"Copy" and "Paste" features to copy the country name into the "Country" text field. If the country
name is not in the list, manually enter the country name into the "Country" text field.
When entering a United States address or location, select the state or territory from the "States"
pull-down list. Selecting a state/territory implies "United States" as the country, so you do not need
to enter it into the "Country" text field. For locations outside of the United States and its territories,
enter the name of the country into the "Country" text field and leave the "State" field blank.
4. 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.
5. For telephone numbers in the United States, be sure to include the area code.
6. All dates provided on this form must be in Month/Day/Year or Month/Year format. Use the pull
down lists to select the month and day. The year should be entered as all four numbers, i.e., 1978 or
2001. 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 checking the "Est." box.
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.
Disclosure of Information
Form Completion Instructions · Instructions for Completing Form SF86
Page 4 of 6
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:
z
z
z
z
z
z
z
z
z
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
Form Completion Instructions · Instructions for Completing Form SF86
z
z
z
z
z
z
z
z
Page 5 of 6
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.
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
Form Completion Instructions · Instructions for Completing Form SF86
Page 6 of 6
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.
c
d
e
f
g
I certify that I have carefully read the foregoing instructions to complete this form.
I Certify
Version 2.00.00
e-QIP: Public Burden Information
Public Burden Information
Page 1 of 1
OMB No. 3206-0005
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.
Sections 1-7: Your Identifying Information · Comprehensive Details
Help · Display · Logout
Navigation: SF86 Sections 1-7: Your Identifying Information
Sections 1-7: Your Identifying Information
Comprehensive Details
Page 1 of 3
Go
OMB No. 3206-0005
Form: SF86
Provide the following information about your identity.
Section 1: Full Name
If you have no first name or middle name, select No First Name (NFN) or No Middle Name
(NMN), as appropriate. If you have only initials in your name, enter the initial(s) (without the
period) and select Initial Only (IO). If you are a "Jr.," "Sr.," etc., enter this under Suffix.
Full Name
Name
IO/NFN/NMN
Last:
First:
Middle:
Suffix:
Section 2: Date of Birth
Date of Birth
Month/Day/Year
/
/
Est.
c
d
e
f
g
Section 3: Place of Birth
Place of Birth
City:
County:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
(List)
Section 5: Other Names Used
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
Sections 1-7: Your Identifying Information · Comprehensive Details
Page 2 of 3
the other name is your maiden name, check the "nee" box.
Other Names Used
c
d
e
f
g
Not Applicable
#
Name
nee
Dates Used
Name
Name
IO/NFN/NMN
Dates Used
Last:
1.
Date
c
d
e
f
g
First:
nee
From:
/
To:
/
Middle:
Suffix:
Add A Blank Entry
Section 6: Mother's Birth Name
Mother's Birth Name
Name
IO/NFN/NMN
Last:
First:
Middle:
Section 7: Your Identifying Information
Height
Feet:
Inches:
Weight (Pounds)
Hair Color
Eye Color
Sex
Month/Year
Est./Pres.
Sections 1-7: Your Identifying Information · Comprehensive Details
Page 3 of 3
c Female
d
e
f
g
c Male
d
e
f
g
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 8: Contact Information · Comprehensive Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 8: Contact Information
Section 8: Contact Information
Comprehensive Details
OMB No. 3206-0005
Form: SF86
Work E-mail Address
Home E-mail Address
Provide your telephone numbers and the time of the day that you are most likely available
at these numbers. Include the Area Code and extension, where applicable.
Work Telephone
Number
Time
Home Telephone
Number
Time
Mobile Telephone
Number
Time
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 9: Citizenship · Comprehensive Details
Page 1 of 4
Go
Navigation: SF86 Section 9: Citizenship
Help · Display · Logout
OMB No. 3206-0005
Form: SF86
Section 9: Citizenship
Comprehensive Details
Mark the box that reflects your current citizenship status and follow its instructions.
Current Citizenship Status
gI
c
d
e
f
am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
c I am a U.S. citizen by birth, born outside the U.S. (Answer item 9A)
d
e
f
g
c I am a naturalized U.S. citizen. (Answer item 9B)
d
e
f
g
c I am not a U.S. citizen. (Answer item 9C)
d
e
f
g
U.S. Passport
Report information from your current or most recent U.S. Passport, if applicable.
c
d
e
f
g
This information is not applicable to me.
Passport Number
Date Issued
Month/Day/Year
/
/
Est.
c
d
e
f
g
Expired?
c Yes
d
e
f
g
c No
d
e
f
g
Item 9A
Report information from Form 240, if applicable.
State Department Form 240 (Report of Birth Abroad of a Citizen of the United States)
c
d
e
f
g
This information is not applicable to me.
Date Form Was Completed
Section 9: Citizenship · Comprehensive Details
Month/Day/Year
/
/
Est.
c
d
e
f
g
Explanation
Item 9B
Citizenship Certificate
Certificate Number
Date Issued
Month/Day/Year
/
/
Est.
c
d
e
f
g
Expired?
g Yes
c
d
e
f
c No
d
e
f
g
Where was this certificate issued?
Court
Location
City:
State:
Naturalization Certificate
Certificate Number
Date Issued
Page 2 of 4
Section 9: Citizenship · Comprehensive Details
Month/Day/Year
/
/
Est.
c
d
e
f
g
Expired?
c Yes
d
e
f
g
g No
c
d
e
f
Where was this certificate issued?
Court
Location
City:
State:
Item 9C
Immigration Status
Place of Entry
City:
State:
Date of Entry
Month/Day/Year
/
/
Est.
c
d
e
f
g
Type of Document
Document Number
Date Issued
Month/Day/Year
/
/
Est.
c
d
e
f
g
Page 3 of 4
Section 9: Citizenship · Comprehensive Details
Page 4 of 4
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 10: Citizenship Information · Comprehensive Details
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 10: Citizenship Information
Section 10: Citizenship Information
Comprehensive Details
OMB No. 3206-0005
Form: SF86
Answer the following question.
Question
Do you now hold or have you ever held multiple citizenships?
If you answered "Yes," provide responses for the following questions.
Item 10A
Provide the name(s) of the country(ies).
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Item 10B
During what periods of time did you hold multiple citizenships?
Time Periods
Item 10C
How were multiple citizenships obtained?
How Obtained
Item 10D
Why have you held multiple citizenships?
Multiple Citizenships Explanation
Yes
No
c
d
e
f
g
c
d
e
f
g
Section 10: Citizenship Information · Comprehensive Details
Page 2 of 2
Item 10E
Have you renounced or attempted to renounce your foreign citizenship?
Renounced/Attempted to Renounce
c Yes
d
e
f
g
c No
d
e
f
g
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 11: Where You Have Lived · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 11: Where You Have Lived
Help · Display · Logout
Section 11: Where You Have Lived
Section Summary
OMB No. 3206-0005
Form: SF86
List the places where you have lived, beginning with your present residence and working
back 10 years (if not an SSBI go back 7 years). All periods must be accounted for without
breaks. You may omit temporary military duty locations under 90 days (list your permanent
address instead). Do not list residences before your 18th birthday unless to provide a
minimum of 2 years of residence history.
Summary of Where You Have Lived
#
Time Period
Street City
1 From (~)/(~) To (~)/(~) (~)
(~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 11: Where You Have Lived · Entry Details
Help · Display · Logout
Page 1 of 3
Go
Navigation: SF86 Section 11: Where You Have Lived
OMB No. 3206-0005
Form: SF86
Section 11: Where You Have Lived
Entry Details
Provide the requested information about this place where you have lived.
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.
Your actual physical address in addition to your APO/FPO address is required for overseas
assignments.
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 under
Additional Comments below.
Include apartment numbers if applicable.
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Status
c Own
d
e
f
g
c Rent
d
e
f
g
c Military
d
e
f
g
Housing
c Other
d
e
f
g
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
If an overseas military assignment, provide APO/FPO address.
Section 11: Where You Have Lived · Entry Details
Page 2 of 3
APO/FPO Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Point of Contact for this Period of Residence
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 5year period, and do not list your spouse, former spouse, or other relatives.
Name of Person Who Knows You (Last, First)
Relationship
g Neighbor
c
d
e
f
c Friend
d
e
f
g
c Landlord
d
e
f
g
c Business
d
e
f
g
Associate
c Other
d
e
f
g
Current Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Provide APO/FPO address if currently applicable.
APO/FPO Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Section 11: Where You Have Lived · Entry Details
Page 3 of 3
Country:
(List)
Telephone Number
Number
Alternate Contact Number
Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 12: Where You Went To School · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 12: Where You Went To School
Help · Display · Logout
Section 12: Where You Went To School
Section Summary
OMB No. 3206-0005
Form: SF86
Item 12A. School Information
List the schools you have attended, beginning with the most recent and working back 10
years (if not an SSBI go back 7 years). 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.
Summary of Where You Went To School
c
d
e
f
g
Not Applicable
#
Time Period
School Name
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Item 12B. Suspension or Expulsion
Answer the following question.
Question
Were you suspended or expelled from any of the institutions above?
Yes
No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes," explain. Do not include academic probations.
Suspension/Expulsion Explanation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 12: Where You Went To School · Entry Details
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 12: Where You Went To School
Section 12: Where You Went To School
Entry Details
OMB No. 3206-0005
Form: SF86
Provide the requested information about this school you attended. List college or
university degrees and the dates they were received. For
Correspondence/Distance/Extension/Online schools, provide the address where the
records are maintained.
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Select the most appropriate type that describes your school.
School Type
c High
d
e
f
g
School
c College/University/Military College
d
e
f
g
c Vocational/Technical/Trade School
d
e
f
g
c Correspondence/Distance/Extension/Online School
d
e
f
g
School Name
Street Address of School
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Provide an entry for each degree, diploma, etc. you received from this school.
Degree/Diploma/Other
c
d
e
f
g
#
Not Applicable
Dates Awarded
Degree/Diploma/Other
Section 12: Where You Went To School · Entry Details
Page 2 of 2
Date Awarded
Month/Year
1.
/
Est.
c
d
e
f
g
Add A Blank Entry
Person Who Knew You
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.
Name (Last, First)
Current Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Telephone Number
Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Section Summary
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 13A/B: Employment Activities
OMB No. 3206-0005
Form: SF86
Section 13A/B: Employment Activities
Section Summary
Item 13A. Employment Information
List your employment activities, beginning with the present and working back 10 years (if
not an SSBI go 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.
Summary of Your Employment Activities
#
Time Period
Type of Employment
1 From (~)/(~) To (~)/(~) (None Selected)
Actions
Edit
Delete
Add an Entry
Item 13B. Former Federal Service
List any former Federal service, excluding Military service, if not indicated previously.
Summary of Your Former Federal Service
c
d
e
f
g
Not Applicable
# Dates of Federal Service Agency Position Title
1 From (~)/(~) To (~)/(~)
(~)
(~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Select Employment Type
Help · Display · Logout
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Select Employment Type
Page 1 of 1
Go
OMB No. 3206-0005
Form: SF86
Check the appropriate box to identify the type of employment.
Type of Employment
g Federal
c
d
e
f
c Military
d
e
f
g
c Military/Federal
d
e
f
g
Contractor
c State Government
d
e
f
g
c Unemployment
d
e
f
g
c Self-employment
d
e
f
g
c Other
d
e
f
g
Save
Cancel
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Employment Activity Details
Help · Display · Logout
Page 1 of 3
Go
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF86
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Type of Employment
Other
Work Hours
g Full-time
c
d
e
f
c Part-time
d
e
f
g
Position Title
List the business name of your employer.
Employer Name
Employer's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Employer's Telephone Number
Number
Your Physical Location (if different from employer address)
Section 13A/B: Employment Activities · Employment Activity Details
Page 2 of 3
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Job Location Telephone Number
Number
Supervisor's Name (Last, First)
Supervisor's Title
Supervisor's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Supervisor's Telephone Number
Number
Provide Additional Periods of Activity if you worked for this employer on more than one
occasion at the same location. After entering the most recent period of employment above,
provide previous periods of employment at the same location in the additional fields
provided below. 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 above, and provide dates, position titles, and supervisors for
the two previous periods of employment as entries below.
Additional Periods of Activity with this Employer
c
d
e
f
g
Not Applicable
Section 13A/B: Employment Activities · Employment Activity Details
#
Dates of Activity
Position Title
Page 3 of 3
Supervisor
Dates of Activity
Date
1.
Month/Year
From:
/
To:
/
Est.
Add A Blank Entry
If this is a former employment or if you intend to leave this position, indicate your reason
for leaving.
Reason for Leaving
c
d
e
f
g
Not Applicable
g Left
c
d
e
f
job under favorable circumstances
c Left job by mutual agreement following charges or allegations of misconduct
d
e
f
g
c Left job by mutual agreement following notice of unsatisfactory performance
d
e
f
g
c Quit job after being told you'd be fired
d
e
f
g
c Fired from job
d
e
f
g
c Laid off from job by employer
d
e
f
g
c Other (explain)
d
e
f
g
Explanation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Employment Activity Details
Help · Display · Logout
Page 1 of 3
Go
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF86
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Type of Employment
Military
Work Hours
g Full-time
c
d
e
f
c Part-time
d
e
f
g
Include your duty location or home port as well as your branch of service. You should
provide separate listings to reflect changes in your military duty locations or home ports.
Service Branch
Military Rank
Military Duty Location
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Country:
(List)
Telephone Number
Number
Zip Code:
Section 13A/B: Employment Activities · Employment Activity Details
Page 2 of 3
Your Physical Location (if different from employer address)
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Job Location Telephone Number
Number
Supervisor's Name (Last, First)
Supervisor's Title
Supervisor's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Supervisor's Telephone Number
Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Section 13A/B: Employment Activities · Employment Activity Details
Save
Cancel
Delete
Page 3 of 3
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Employment Activity Details
Help · Display · Logout
Page 1 of 3
Go
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF86
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Type of Employment
Military/Federal Contractor
Work Hours
g Full-time
c
d
e
f
c Part-time
d
e
f
g
Position Title
List contract, not federal agency.
Employer Name
Employer's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Employer's Telephone Number
Number
Your Physical Location (if different from employer address)
Section 13A/B: Employment Activities · Employment Activity Details
Page 2 of 3
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Job Location Telephone Number
Number
Supervisor's Name (Last, First)
Supervisor's Title
Supervisor's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Supervisor's Telephone Number
Number
Provide Additional Periods of Activity if you worked for this employer on more than one
occasion at the same location. After entering the most recent period of employment above,
provide previous periods of employment at the same location in the additional fields
provided below. 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 above, and provide dates, position titles, and supervisors for
the two previous periods of employment as entries below.
Additional Periods of Activity with this Employer
c
d
e
f
g
Not Applicable
Section 13A/B: Employment Activities · Employment Activity Details
#
Dates of Activity
Position Title
Page 3 of 3
Supervisor
Dates of Activity
Date
1.
Month/Year
From:
/
To:
/
Est.
Add A Blank Entry
If this is a former employment or if you intend to leave this position, indicate your reason
for leaving.
Reason for Leaving
c
d
e
f
g
Not Applicable
g Left
c
d
e
f
job under favorable circumstances
c Left job by mutual agreement following charges or allegations of misconduct
d
e
f
g
c Left job by mutual agreement following notice of unsatisfactory performance
d
e
f
g
c Quit job after being told you'd be fired
d
e
f
g
c Fired from job
d
e
f
g
c Laid off from job by employer
d
e
f
g
c Other (explain)
d
e
f
g
Explanation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Employment Activity Details
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF86
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Type of Employment
Self-employment
Work Hours
g Full-time
c
d
e
f
c Part-time
d
e
f
g
Occupation
Business Name
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Telephone Number
Number
List the name of the person who can verify your self-employment.
Verifier Name
Section 13A/B: Employment Activities · Employment Activity Details
Page 2 of 2
Verifier's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Verifier's Telephone Number
Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Employment Activity Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF86
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Type of Employment
Unemployment
List the name of the person who can verify your unemployment.
Verifier Name
Verifier's Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Verifier's Telephone Number
Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 13A/B: Employment Activities · Former Federal Service Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 13A/B: Employment Activities
Section 13A/B: Employment Activities
Former Federal Service Details
OMB No. 3206-0005
Form: SF86
Dates of Federal Service
Date
Month/Year
From:
/
To:
/
Est.
Your Position Title
Agency Name
Location
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 13C: Employment Activities (Continued) · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 13C: Employment Activities (Continued)
Help · Display · Logout
Section 13C: Employment Activities (Continued)
Section Summary
OMB No. 3206-0005
Form: SF86
Answer the following questions.
#
Question
Yes No
1. In the last 7 years, have you received a written warning, been officially reprimanded,
suspended, or disciplined for misconduct in the workplace?
c
d
e
f
g
c
d
e
f
g
2. In the last 7 years, have you received a written warning, been officially reprimanded,
suspended, or disciplined for violating a security rule or policy?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to either question, provide an entry for each incident.
Summary of Incidents
# Date of Incident Name of Employer(s)
1 (~)/(~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 13C: Employment Activities (Continued) · Entry Details
Page 1 of 1
Go
Navigation: SF86 Section 13C: Employment Activities (Continued)
Help · Display · Logout
Section 13C: Employment Activities (Continued)
Entry Details
OMB No. 3206-0005
Form: SF86
Date of Incident
Month/Day/Year
/
/
Est.
c
d
e
f
g
Date of Official Action
Month/Year
/
Est.
c
d
e
f
g
Name of Employer(s)
Location or Facility of Incident
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Nature of Violation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 14: Selective Service Record · Comprehensive Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 14: Selective Service Record
Section 14: Selective Service Record
Comprehensive Details
OMB No. 3206-0005
Form: SF86
Answer the following question.
#
Question
a. Are you a male born after December 31, 1959?
Yes
No
c
d
e
f
g
c
d
e
f
g
Yes
No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question a, answer the following question.
#
Question
b. Have you registered with the Selective Service System?
If you answered "Yes" to question b, provide your registration number. If "No," explain the
reason for not registering.
Registration Number
Explanation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 15: Military History · Section Summary
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 15: Military History
OMB No. 3206-0005
Form: SF86
Section 15: Military History
Section Summary
Account for all of your military service through the questions below.
Answer the following questions.
#
Question
Yes No
a. Have you EVER served in the United States Military, the United States Merchant
Marine, or the commissioned corps of the United States Public Health Service
(PHS) or National Oceanic and Atmospheric Administration (NOAA)?
c
d
e
f
g
c
d
e
f
g
b. Have you EVER served in the military, security forces, merchant marine, militia, or
other defense forces of any foreign country?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question a or b, list all details of your military service below. If
you had a break in service, each separate time of service should be listed.
Summary of Your Military Service
c
d
e
f
g
#
Not Applicable
Time Period
Branch of Service
1 From (~)/(~) To (~)/(~) (None Selected)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
c. Have you EVER received other than an honorable discharge?
Yes
No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question c, explain.
Explanation
Answer the following question.
#
Question
d. Have you EVER been subject to an Article 15 or been charged with any violation of
the Uniform Code of Military Justice?
If you answered "Yes" to question d, provide an entry for each charge.
Yes No
c
d
e
f
g
c
d
e
f
g
Section 15: Military History · Section Summary
Page 2 of 2
Summary of Your Military Charges
#
Date Charged
Actions
1 From (~)/(~) To (~)/(~) Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 15: Military History · Select Branch of Service
Help · Display · Logout
Navigation: SF86 Section 15: Military History
Section 15: Military History
Select Branch of Service
Page 1 of 1
Go
OMB No. 3206-0005
Form: SF86
Use one of the codes listed below to identify your branch of service:
Branch of Service
g Air
c
d
e
f
Force
c Army
d
e
f
g
c Navy
d
e
f
g
c Marine Corps
d
e
f
g
c Coast Guard
d
e
f
g
c Merchant Marine
d
e
f
g
c National Guard
d
e
f
g
c United States Public Health Service (PHS)
d
e
f
g
c National Oceanic and Atmospheric Administration (NOAA)
d
e
f
g
c Foreign military, defense, militia, security forces
d
e
f
g
Save
Cancel
Reset this Screen
Version 2.00.00
Section 15: Military History · Service Details
Help · Display · Logout
Navigation: SF86 Section 15: Military History
Section 15: Military History
Service Details
Branch of Service
Air Force
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Service/Certificate Number
Mark Officer or Enlisted, if applicable.
Officer or Enlisted
c
d
e
f
g
Not Applicable
c Officer
d
e
f
g
c Enlisted
d
e
f
g
Indicate the status of your service during the time that you served.
Status
c Active
d
e
f
g
Duty
Active
Reserve
c
d
e
f
g
c Inactive Reserve
d
e
f
g
Type of Discharge
c
d
e
f
g
Not Applicable
c Honorable
d
e
f
g
c Dishonorable
d
e
f
g
c Hardship
d
e
f
g
c Medical
d
e
f
g
c Other
d
e
f
g
If you selected "Other" for "Type of Discharge," explain.
Explanation
Page 1 of 2
Go
OMB No. 3206-0005
Form: SF86
Section 15: Military History · Service Details
Page 2 of 2
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 15: Military History · Service Details
Help · Display · Logout
Navigation: SF86 Section 15: Military History
Section 15: Military History
Service Details
Branch of Service
National Guard
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Service/Certificate Number
Mark Officer or Enlisted, if applicable.
Officer or Enlisted
c
d
e
f
g
Not Applicable
c Officer
d
e
f
g
c Enlisted
d
e
f
g
State of Service
State:
Type of Discharge
c
d
e
f
g
Not Applicable
c Honorable
d
e
f
g
c Dishonorable
d
e
f
g
c Hardship
d
e
f
g
c Medical
d
e
f
g
c Other
d
e
f
g
If you selected "Other" for "Type of Discharge," explain.
Explanation
Page 1 of 2
Go
OMB No. 3206-0005
Form: SF86
Section 15: Military History · Service Details
Page 2 of 2
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 15: Military History · Service Details
Help · Display · Logout
Navigation: SF86 Section 15: Military History
Section 15: Military History
Service Details
Branch of Service
Foreign military, defense, militia, security forces
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Service/Certificate Number
Mark Officer or Enlisted, if applicable.
Officer or Enlisted
c
d
e
f
g
Not Applicable
c Officer
d
e
f
g
c Enlisted
d
e
f
g
Indicate the status of your service during the time that you served.
Status
c Active
d
e
f
g
Duty
Active
Reserve
c
d
e
f
g
c Inactive Reserve
d
e
f
g
Identify the country for which you served.
Country
Country:
(List)
Type of Discharge
c
d
e
f
g
Not Applicable
c Honorable
d
e
f
g
c Dishonorable
d
e
f
g
Page 1 of 2
Go
OMB No. 3206-0005
Form: SF86
Section 15: Military History · Service Details
Page 2 of 2
c Hardship
d
e
f
g
c Medical
d
e
f
g
c Other
d
e
f
g
If you selected "Other" for "Type of Discharge," explain.
Explanation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Delete
Reset this Screen
Version 2.00.00
Section 16: People Who Know You Well · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 16: People Who Know You Well
Help · Display · Logout
Section 16: People Who Know You Well
Section Summary
OMB No. 3206-0005
Form: SF86
List three people who know you well and preferably who live in the United States. 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.
Summary of People Who Know You Well
#
Dates Known
Reference Name
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 16: People Who Know You Well · Entry Details
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 16: People Who Know You Well
Section 16: People Who Know You Well
Entry Details
OMB No. 3206-0005
Form: SF86
Dates Known
Date
Month/Year
From:
/
To:
/
Est./Pres.
Reference Name (Last, First)
Relationship to You
g Neighbor
c
d
e
f
c Friend
d
e
f
g
c Work
d
e
f
g
Associate
c Schoolmate
d
e
f
g
c Other
d
e
f
g
Include apartment number, if applicable.
Home or Work Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Telephone Number
Number
Time
Alternate Telephone Number
Number
Time
Section 16: People Who Know You Well · Entry Details
Page 2 of 2
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 17: Marital Status · Section Summary
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 17: Marital Status
Section 17: Marital Status
Section Summary
OMB No. 3206-0005
Form: SF86
Mark one box to show your current marital status.
Marital Status
g Never
c
d
e
f
Married
c Married (including Common Law)
d
e
f
g
c Separated
d
e
f
g
c Divorced
d
e
f
g
c Annulled
d
e
f
g
c Widowed
d
e
f
g
Item 17A. Current Spouse
Complete the following about your current spouse only.
Current Spouse
c
d
e
f
g
Not Applicable
Full Name Date Married
(~), (~) (~) (~)/(~)/(~)
Actions
Edit
Delete
Item 17B. Former Spouse(s)
Complete the following about your former spouse(s).
Former Spouse(s)
c
d
e
f
g
Not Applicable
# Full Name Date Married
1 (~), (~) (~) (~)/(~)/(~)
Actions
Edit
Delete
Add an Entry
Item 17C. Cohabitant
Complete the following about your cohabitant. (A cohabitant is a person with whom you
live in a spouse-like relationship and share bonds of affection, obligation or other
commitments.)
Section 17: Marital Status · Section Summary
Page 2 of 2
Cohabitant
c
d
e
f
g
Not Applicable
# Full Name
1 (~), (~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 17: Marital Status · Your Current Spouse
Page 1 of 4
Go
Navigation: SF86 Section 17: Marital Status
Help · Display · Logout
OMB No. 3206-0005
Form: SF86
Section 17: Marital Status
Your Current Spouse
If no first name or middle name is used, select No First Name (NFN) or No Middle Name
(NMN), as appropriate. If only an initial is used as the first name or middle name, enter the
initial (without the period) and select Initial Only (IO). If this person is a "Jr.," "Sr.," etc.,
enter this under Suffix.
Full Name
Name
IO/NFN/NMN
Last:
First:
Middle:
Suffix:
Date of Birth
Month/Day/Year
/
Est.
/
c
d
e
f
g
Social Security Number
c
d
e
f
g
Not Applicable
-
-
Specify maiden name, names by other marriages, etc., and show dates used for each name.
Check the "nee" box to denote maiden name.
Other Names Used
c
d
e
f
g
Not Applicable
#
Name
nee
Name
Name
Last:
1.
First:
Middle:
Dates Used
Dates Used
IO/NFN/NMN
Date
c
d
e
f
g
nee
Month/Year
From:
/
To:
/
Est./Pres.
Section 17: Marital Status · Your Current Spouse
Page 2 of 4
Suffix:
Add A Blank Entry
Provide current address and telephone number only if different than your current address;
otherwise, check the "Use My Current Address" box.
Current Address
c
d
e
f
g
Use My Current Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Telephone Number
Number
Date Married
Month/Day/Year
/
/
Est.
c
d
e
f
g
Place Married
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
If separated, provide date of separation.
Date of Separation
Month/Day/Year
/
/
Est.
c
d
e
f
g
Section 17: Marital Status · Your Current Spouse
Page 3 of 4
If legally separated, where is the record located?
Location of Separation Record
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Citizenship Information
Place of Birth
City:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
(List)
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
If this person was born outside the U.S., check the appropriate box and provide document
number.
Type of Document
c
d
e
f
g
Not Applicable
c Naturalization
d
e
f
g
Certificate
Citizenship
Certificate
c
d
e
f
g
c State Department Form 240
d
e
f
g
c U.S. Passport (current or most recent)
d
e
f
g
c Alien Registration
d
e
f
g
c Other
d
e
f
g
Document Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Section 17: Marital Status · Your Current Spouse
Save
Cancel
Page 4 of 4
Reset this Screen
Version 2.00.00
Section 17: Marital Status · Your Former Spouse
Help · Display · Logout
Navigation: SF86 Section 17: Marital Status
Section 17: Marital Status
Your Former Spouse
Page 1 of 3
Go
OMB No. 3206-0005
Form: SF86
Status of Former Marriage
c Divorced
d
e
f
g
c Widowed
d
e
f
g
g Annulled
c
d
e
f
If not widowed, is this person deceased?
Deceased
c Yes
d
e
f
g
c No
d
e
f
g
If no first name or middle name is used, select No First Name (NFN) or No Middle Name
(NMN), as appropriate. If this person has only initials in the name, enter the initial(s)
(without the period) and select Initial Only (IO). If this person is a "Jr.," "Sr.," etc., enter this
under Suffix.
Full Name
Name
IO/NFN/NMN
Last:
First:
Middle:
Suffix:
Date of Birth
Month/Day/Year
/
/
Est.
c
d
e
f
g
Place of Birth
City:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
(List)
Section 17: Marital Status · Your Former Spouse
Page 2 of 3
Countries of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Date Married
Month/Day/Year
/
/
Est.
c
d
e
f
g
Place Married
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Date Divorced/Widowed/Annulled
Month/Year
/
Est.
c
d
e
f
g
If divorced/annulled, provide the following information.
Location of Divorce/Annulment Record
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Last Known Address of Former Spouse
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Country:
(List)
Zip Code:
Section 17: Marital Status · Your Former Spouse
Page 3 of 3
Telephone Number
Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 17: Marital Status · Your Cohabitant
Page 1 of 3
Go
Navigation: SF86 Section 17: Marital Status
Help · Display · Logout
OMB No. 3206-0005
Form: SF86
Section 17: Marital Status
Your Cohabitant
If no first name or middle name is used, select No First Name (NFN) or No Middle Name
(NMN), as appropriate. If only an initial is used as the first name or middle name, enter the
initial (without the period) and select Initial Only (IO). If this person is a "Jr.," "Sr.," etc.,
enter this under Suffix.
Full Name
Name
IO/NFN/NMN
Last:
First:
Middle:
Suffix:
Date of Birth
Month/Day/Year
/
Est.
/
c
d
e
f
g
Social Security Number
c
d
e
f
g
Not Applicable
-
-
Specify maiden name, names by other marriages, etc., and show dates used for each name.
Check the "nee" box to denote maiden name.
Other Names Used
c
d
e
f
g
Not Applicable
#
Name
nee
Name
Name
Last:
1.
First:
Middle:
Dates Used
Dates Used
IO/NFN/NMN
Date
c
d
e
f
g
nee
Month/Year
From:
/
To:
/
Est./Pres.
Section 17: Marital Status · Your Cohabitant
Page 2 of 3
Suffix:
Add A Blank Entry
Date Cohabitation Began
Month/Day/Year
/
/
Est.
c
d
e
f
g
Citizenship Information
Place of Birth
City:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
(List)
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
If this person was born outside the U.S., check the appropriate box and provide document
number.
Type of Document
c
d
e
f
g
Not Applicable
g Naturalization
c
d
e
f
Certificate
c Citizenship Certificate
d
e
f
g
c State Department Form 240
d
e
f
g
c U.S. Passport (current or most recent)
d
e
f
g
c Alien Registration
d
e
f
g
c Other
d
e
f
g
Document Number
Section 17: Marital Status · Your Cohabitant
Page 3 of 3
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 18: Relatives · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 18: Relatives
Help · Display · Logout
OMB No. 3206-0005
Form: SF86
Section 18: Relatives
Section Summary
Give the full name and other requested information for each of your relatives and
associates, living or deceased, specified below.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Mother
Father
Stepmother
Stepfather
Foster Parent
Child (include adopted and foster)
Stepchild
Brother
Sister
Stepbrother
Stepsister
Half-brother
Half-sister
Father-in-law
Mother-in-law
Guardian
Summary of Your Relatives
# Relationship Type Full Name
1 (None Selected)
(~), (~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 18: Relatives · Entry Details
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 18: Relatives
OMB No. 3206-0005
Form: SF86
Section 18: Relatives
Entry Details
Relationship Type
If no first name or middle name is used, select No First Name (NFN) or No Middle Name
(NMN), as appropriate. If only an initial is used as the first name or middle name, enter the
initial (without the period) and select Initial Only (IO). If this person is a "Jr.," "Sr.," etc.,
enter this under Suffix.
Full Name
Name
IO/NFN/NMN
Last:
First:
Middle:
Suffix:
Deceased
c Yes
d
e
f
g
c No
d
e
f
g
Date of Birth
Month/Day/Year
/
/
Est.
c
d
e
f
g
Provide the current address of living relatives.
Current Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Country:
(List)
Citizenship Information
Zip Code:
Section 18: Relatives · Entry Details
Page 2 of 2
Country of Birth
Country:
(List)
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Citizenship Status
c a)
d
e
f
g
U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth
U.S. citizen by birth, born outside the U.S.
c c) Naturalized U.S. citizen
d
e
f
g
c d) Not a U.S. citizen
d
e
f
g
c e) Other
d
e
f
g
c b)
d
e
f
g
If you selected Citizenship Status code b, c, d, or e, provide the following citizenship
information about this person.
Type of Document
c
d
e
f
g
Not Applicable
g Naturalization
c
d
e
f
Certificate
c Citizenship Certificate
d
e
f
g
c State Department Form 240
d
e
f
g
c U.S. Passport (current or most recent)
d
e
f
g
c Alien Registration
d
e
f
g
c Other
d
e
f
g
Document Number
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 19: Foreign Contacts · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 19: Foreign Contacts
Help · Display · Logout
Section 19: Foreign Contacts
Section Summary
OMB No. 3206-0005
Form: SF86
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.
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.
Summary of Foreign Contacts
c
d
e
f
g
Not Applicable
#
Dates Known
Full Name
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 19: Foreign Contacts · Entry Details
Page 1 of 2
Go
Navigation: SF86 Section 19: Foreign Contacts
Help · Display · Logout
Section 19: Foreign Contacts
Entry Details
OMB No. 3206-0005
Form: SF86
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.
Dates Known
Date
Month/Year
From:
/
To:
/
Est./Pres.
Full Name (Last, First, Middle)
Approximate Current Age
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Nature of Relationship (Check all that apply)
Business
c Personal
d
e
f
g
c Other
d
e
f
g
c
d
e
f
g
Type of Contact (Check all that apply)
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Telephone
Electronic Correspondence
Written Correspondence
In Person
Other
Number of Contacts per year
c 1-2
d
e
f
g
Section 19: Foreign Contacts · Entry Details
Page 2 of 2
c 3-7
d
e
f
g
c 8-15
d
e
f
g
c More
d
e
f
g
than 15
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20A: Foreign Financial Interests · Section Summary
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 20A: Foreign Financial Interests
Section 20A: Foreign Financial Interests
Section Summary
OMB No. 3206-0005
Form: SF86
For the following questions, please respond for the timeframe of the past 7 years.
Answer the following question.
#
Question
Yes No
1. Do you have or have you had any foreign financial interests of which you have direct
control or direct ownership?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question 1, provide the purpose and amount of funds for each
interest.
Direct Foreign Financial Interests
#
Amount of
Funds in U.S.
Dollars
Purpose
1.
Add A Blank Entry
Answer the following question.
#
Question
2. Do you have or have you had any foreign financial interests that someone controls
on your behalf?
Yes No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question 2, provide the purpose and amount of funds for each
interest.
Indirect Foreign Financial Interests
#
Purpose
Amount of
Funds in U.S.
Dollars
1.
Add A Blank Entry
Answer the following question.
#
Question
3. Do you own or have you owned real estate in a foreign country?
Yes
No
c
d
e
f
g
c
d
e
f
g
Section 20A: Foreign Financial Interests · Section Summary
Page 2 of 2
If you answered "Yes" to question 3, provide an entry for each foreign real estate holding.
Summary of Foreign Real Estate Holdings
# Location of Property Estimated Value of Property in U.S. Dollars
1 (~)
(~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 20A: Foreign Financial Interests · Foreign Real Estate Holding Entry Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 20A: Foreign Financial Interests
Section 20A: Foreign Financial Interests
Foreign Real Estate Holding Entry Details
OMB No. 3206-0005
Form: SF86
Type of Property
Location of Property
City:
Country:
(List)
Estimated Value of Property in U.S. Dollars
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Section Summary
Help · Display · Logout
Page 1 of 3
Go
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Section 20B: Foreign Activities and Government
Contacts
OMB No. 3206-0005
Form: SF86
Section Summary
Answer the following question.
#
Question
Yes No
1. In the past 7 years, 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?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question 1 AND the activity was outside of official U.S.
Government business, provide entries to describe the advice/support provided.
Summary of Advice/Support Activities
#
Dates of Activity
Organization(s)
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
2. In the past 7 years, have you attended two or more international conferences, trade
shows, seminars, or other meetings outside of the U.S.?
Yes No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question 2 AND the activity was outside of official U.S.
Government business, provide an entry for each event.
Summary of Meetings
# Date of Event Location
1 (~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
3. In the past 7 years, have you been asked to provide advice or serve as a consultant,
even informally, by any foreign government official or agency?
If you answered "Yes" to question 3 AND the activity was outside of official U.S.
Government business, provide an entry for for each consultation.
Yes No
c
d
e
f
g
c
d
e
f
g
Section 20B: Foreign Activities and Government Contacts · Section Summary
Page 2 of 3
Summary of Consultations
# Date of Consultation Location
1 (~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
Yes No
4. In the past 7 years, have you had any contact with a foreign government, its
establishment (embassies or consulates), or its representatives, whether inside or
outside the U.S.?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question 4 AND the activity was outside of official U.S.
Government business, provide an entry for each contact.
Summary of Government Contacts
# Date of Contact Foreign Country
1 (~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
Yes No
5. In the past 7 years, have you sponsored any foreign citizen to come to the U.S. as a
student, for work, or for permanent residence?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question 5, provide an entry for each foreign citizen you
sponsored.
Summary of Sponsored Visits
#
Dates of Stay
Name of Foreign Citizen(s)
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
6. In the past 7 years, have you held or do you hold a passport that was issued by a
foreign government?
Yes No
c
d
e
f
g
If you answered "Yes" to question 6, provide an entry for each foreign passport held.
Summary of Foreign Passports
c
d
e
f
g
Section 20B: Foreign Activities and Government Contacts · Section Summary
# Issuing Country Passport Number
1 (~)
(~)
Page 3 of 3
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Advice/Support Activity Entry Details Page 1 of 1
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Help · Display · Logout
Section 20B: Foreign Activities and Government
Contacts
Go
OMB No. 3206-0005
Form: SF86
Advice/Support Activity Entry Details
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Describe Advice/Support Provided
Provide name of foreign nationals and/or organization(s) to which advice/support was
provided.
Foreign National Names/Organizations
Country(ies) Involved
#
Country
1.
(List)
Add A Blank Entry
Was Compensation Provided?
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Meeting Entry Details
Page 1 of 1
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Help · Display · Logout
Section 20B: Foreign Activities and Government
Contacts
Go
OMB No. 3206-0005
Form: SF86
Meeting Entry Details
Date of Event
Month/Year
Est.
/
c
d
e
f
g
Location of Event
City:
Country:
(List)
Country(ies) Involved
#
Country
1.
(List)
Add A Blank Entry
Sponsoring Organization(s)
Purpose
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Consultation Entry Details
Page 1 of 1
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Help · Display · Logout
Section 20B: Foreign Activities and Government
Contacts
Go
OMB No. 3206-0005
Form: SF86
Consultation Entry Details
Date of Consultation
Month/Year
Est.
/
c
d
e
f
g
Location of Consultation
City:
Country:
(List)
Country(ies) Involved
#
Country
1.
(List)
Add A Blank Entry
Circumstances
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Government Contact Entry Details
Page 1 of 1
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Help · Display · Logout
Section 20B: Foreign Activities and Government
Contacts
Go
OMB No. 3206-0005
Form: SF86
Government Contact Entry Details
Date of Contact
Month/Year
Est.
/
c
d
e
f
g
Location of Contact
City:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
(List)
Country(ies) Involved
#
Country
1.
(List)
Add A Blank Entry
Circumstances
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Sponsored Visit Entry Details
Page 1 of 2
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Help · Display · Logout
Section 20B: Foreign Activities and Government
Contacts
OMB No. 3206-0005
Form: SF86
Sponsored Visit Entry Details
Dates of Stay
Date
Month/Year
From:
/
To:
/
Est./Pres.
Name of Foreign Citizen(s)
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Purpose of Stay
Current Address (if known)
c
d
e
f
g
Do Not Know
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Go
Zip Code:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Section 20B: Foreign Activities and Government Contacts · Sponsored Visit Entry Details
Save
Cancel
Page 2 of 2
Reset this Screen
Version 2.00.00
Section 20B: Foreign Activities and Government Contacts · Foreign Passport Entry Details
Page 1 of 1
Navigation: SF86 Section 20B: Foreign Activities and Government Contacts
Help · Display · Logout
Section 20B: Foreign Activities and Government
Contacts
Go
OMB No. 3206-0005
Form: SF86
Foreign Passport Entry Details
Name in which Passport was Issued
Issuing Country
Country:
(List)
Passport Number
Issue Date
Month/Year
Est.
/
c
d
e
f
g
Expiration Date
Month/Year
/
Est.
c
d
e
f
g
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 20C: Foreign Countries You Have Visited · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 20C: Foreign Countries You Have Visited
Help · Display · Logout
Section 20C: Foreign Countries You Have Visited
Section Summary
OMB No. 3206-0005
Form: SF86
List foreign countries you have visited in the past 7 years.
Summary of Foreign Countries You Have Visited
c
d
e
f
g
Not Applicable
#
Time Period
Country(ies)
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 20C: Foreign Countries You Have Visited · Entry Details
Page 1 of 2
Navigation: SF86 Section 20C: Foreign Countries You Have Visited
Help · Display · Logout
Section 20C: Foreign Countries You Have Visited
Entry Details
Go
OMB No. 3206-0005
Form: SF86
Indicate the purpose(s) of your visit. If you 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 purpose, the country, and check the "Many
Short Trips" box.
Dates of Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Purpose of Visit (Check all that apply)
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
c
d
e
f
g
Business/Professional Conference
Education
Volunteer Activities
Tourism
Visit Family or Friends
Other
Countries Visited
#
Country
1.
(List)
Add A Blank Entry
Number of Days
c
d
e
f
g
Many Short Trips
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Section 20C: Foreign Countries You Have Visited · Entry Details
Page 2 of 2
Version 2.00.00
Section 21: Mental and Emotional Health · Section Summary
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 21: Mental and Emotional Health
Section 21: Mental and Emotional Health
Section Summary
OMB No. 3206-0005
Form: SF86
Answer the following question.
Question
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.
c
d
e
f
g
c
d
e
f
g
If you answered "Yes," provide a record for each treatment to report, and sign the
Authorization for Release of Medical Information Pursuant to the Health Insurance
Portability and Accountability Act (HIPAA) (provided to you after you complete this form).
Summary of Treatments
# Dates of Treatment Name of Provider
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 21: Mental and Emotional Health · Entry Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 21: Mental and Emotional Health
Section 21: Mental and Emotional Health
Entry Details
OMB No. 3206-0005
Form: SF86
Dates of Treatment
Date
Month/Year
From:
/
To:
/
Est./Pres.
Indicate who conducted the treatment.
Name of Provider
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Explain Circumstances of Treatment
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 22: Police Record · Section Summary
Page 1 of 2
Go
Navigation: SF86 Section 22: Police Record
Help · Display · Logout
OMB No. 3206-0005
Form: SF86
Section 22: Police Record
Section Summary
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 and b for the past 10 years (if not an SSBI go back 7 years) excluding
any fines of less than $300 for traffic offenses that do not involve alcohol or drugs.
Answer the following questions.
#
Question
Yes No
a. 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?
c
d
e
f
g
c
d
e
f
g
b. Have you been detained or arrested by any police officer, sheriff, marshal, or any
other type of law enforcement officer?
c
d
e
f
g
c
d
e
f
g
c. Have you EVER been charged with any felony offense? (Include those under
Uniform Code of Military Justice.)
c
d
e
f
g
c
d
e
f
g
d. Have you EVER been charged with a firearms or explosives offense?
c
d
e
f
g
c
d
e
f
g
e. Have you EVER been charged with any offense(s) related to alcohol or drugs?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to any question above, explain below, providing information for each
and every offense.
Summary of Offenses
# Date Offense
1 (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Section 22: Police Record · Section Summary
Page 2 of 2
Version 2.00.00
Section 22: Police Record · Entry Details
Page 1 of 2
Go
Navigation: SF86 Section 22: Police Record
Help · Display · Logout
OMB No. 3206-0005
Form: SF86
Section 22: Police Record
Entry Details
Date of Offense
Month/Year
Est.
/
c
d
e
f
g
Offense
Disposition
Law Enforcement Authority/Court
c
d
e
f
g
Not Applicable
Name
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Section 22: Police Record · Entry Details
Page 2 of 2
Version 2.00.00
Section 23: Use of Illegal Drugs and Drug Activity · Section Summary
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 23: Use of Illegal Drugs and Drug Activity
Section 23: Use of Illegal Drugs and Drug Activity
Section Summary
OMB No. 3206-0005
Form: SF86
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.
Answer the following questions.
#
Question
Yes No
a. In the last 7 years, have you illegally used any controlled substance, for example,
cocaine, crack cocaine, THC (marijuana, hashish, 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)? Illegal use of a controlled
substance includes injecting, snorting, inhaling, swallowing, experimenting with or
otherwise consuming any controlled substance.
c
d
e
f
g
c
d
e
f
g
b. 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?
c
d
e
f
g
c
d
e
f
g
c. 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?
c
d
e
f
g
c
d
e
f
g
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.
Summary of Substance/Drug Use/Activity
# Dates of Use/Activity Type of Controlled Substance(s)
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Section 23: Use of Illegal Drugs and Drug Activity · Section Summary
Page 2 of 2
Version 2.00.01
Section 23: Use of Illegal Drugs and Drug Activity · Entry Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 23: Use of Illegal Drugs and Drug Activity
Section 23: Use of Illegal Drugs and Drug Activity
Entry Details
OMB No. 3206-0005
Form: SF86
Dates of Use/Activity
Date
Month/Year
From:
/
To:
/
Est./Pres.
Type of Controlled Substance(s)
Explain Nature of Use/Activity, Frequency of Activity, and Number of Times Used
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.01
Section 24: Use of Alcohol · Section Summary
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 24: Use of Alcohol
OMB No. 3206-0005
Form: SF86
Section 24: Use of Alcohol
Section Summary
Answer the following question.
#
Question
Yes No
a. In the last 7 years, has your use of alcohol had a negative impact on your work
performance, your professional or personal relationships, your finances, or resulted
in contacts by law enforcement/public safety personnel?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question a, explain.
Explanation
Answer the following question.
#
Question
Yes No
b. In the last 7 years, 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?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question b above, provide an entry for each treatment to report.
You will be asked to sign a release if information is needed concerning your treatment. Do
not repeat information reported in response to Section 21 (Mental and Emotional Health).
Summary of Treatments
# Dates of Treatment Counselor/Doctor
1 From (~)/(~) To (~)/(~) (~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.01
Section 24: Use of Alcohol · Entry Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 24: Use of Alcohol
OMB No. 3206-0005
Form: SF86
Section 24: Use of Alcohol
Entry Details
Provide the dates of treatment and the name and address of the counselor or doctor.
Dates of Treatment
Date
Month/Year
From:
/
To:
/
Est./Pres.
Name of Counselor/Doctor
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 25: Investigations Record · Section Summary
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 25: Investigations Record
OMB No. 3206-0005
Form: SF86
Section 25: Investigations Record
Section Summary
Answer the following question.
#
Question
Yes No
a. Has the United States Government or a foreign government EVER investigated your
background and/or granted you a security clearance? If your response is "No," or
you don't know or can't recall if you were investigated and cleared, check the "No"
box.
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question a, provide the requested information below.
Summary of Your Investigations
# Month/Year Agency Code Other Agency Clearance Code
1 (~)/(~)
(~)
(~)
(~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
Yes No
b. 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?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to question b, provide the requested information below.
Summary of Your Clearance/Access Actions
# Month/Year Department or Agency Taking Action
1 (~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Answer the following question.
#
Question
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 you answered "Yes" to question c, provide the requested information below.
Summary of Your Withdrawals
Yes No
c
d
e
f
g
c
d
e
f
g
Section 25: Investigations Record · Section Summary
# Month/Year Agency
1 (~)/(~)
(~)
Page 2 of 2
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 25: Investigations Record · Investigation Entry Details
Page 1 of 2
Go
Navigation: SF86 Section 25: Investigations Record
Help · Display · Logout
Section 25: Investigations Record
Investigation Entry Details
OMB No. 3206-0005
Form: SF86
Provide the requested information. If you do not know the requested information, check the
associated "Do Not Know" box.
Date of Action
c
d
e
f
g
Do Not Know
Month/Year
/
Est.
c
d
e
f
g
Agency Code
c
d
e
f
g
Do Not Know
g Defense
c
d
e
f
Department
c State Department
d
e
f
g
c Office of Personnel Management
d
e
f
g
c Federal Bureau of Investigation
d
e
f
g
c Treasury Department
d
e
f
g
c Department of Homeland Security
d
e
f
g
c Other (Specify)
d
e
f
g
Other Agency
Clearance Code
c
d
e
f
g
Do Not Know
c Not
d
e
f
g
Required
c Confidential
d
e
f
g
c Secret
d
e
f
g
c Top Secret
d
e
f
g
c Sensitive Compartmented Information
d
e
f
g
cQ
d
e
f
g
cL
d
e
f
g
c Issued by Foreign Country
d
e
f
g
c Other
d
e
f
g
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Section 25: Investigations Record · Investigation Entry Details
Save
Cancel
Page 2 of 2
Reset this Screen
Version 2.00.00
Section 25: Investigations Record · Clearance/Access Action Entry Details
Page 1 of 1
Go
Navigation: SF86 Section 25: Investigations Record
Help · Display · Logout
Section 25: Investigations Record
Clearance/Access Action Entry Details
OMB No. 3206-0005
Form: SF86
Provide the requested information about this clearance or access authorization denial,
suspension, or revocation, or government employment debarment.
Date of Action
Month/Year
/
Est.
c
d
e
f
g
Department or Agency Taking Action
Circumstances
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 25: Investigations Record · Withdrawal Entry Details
Page 1 of 1
Go
Navigation: SF86 Section 25: Investigations Record
Help · Display · Logout
Section 25: Investigations Record
Withdrawal Entry Details
OMB No. 3206-0005
Form: SF86
Provide the agency, position, date of application, and reason for withdrawal.
Date of Application
Month/Year
/
Est.
c
d
e
f
g
Agency
Position
Reason for Withdrawal
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 26: Financial Record · Section Summary
Help · Display · Logout
Page 1 of 2
Go
Navigation: SF86 Section 26: Financial Record
OMB No. 3206-0005
Form: SF86
Section 26: Financial Record
Section Summary
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.
Answer the following questions.
#
Question
Yes No
a. Have you filed a petition under any chapter of the bankruptcy code?
c
d
e
f
g
c
d
e
f
g
b. Have you had any possessions or property voluntarily or involuntarily repossessed
or foreclosed?
c
d
e
f
g
c
d
e
f
g
c. Have you failed to pay Federal, state, or other taxes, or to file a tax return, when
required by law or ordinance?
c
d
e
f
g
c
d
e
f
g
d. Have you had a lien placed against your property for failing to pay taxes or other
debts?
c
d
e
f
g
c
d
e
f
g
e. Have you had a judgment entered against you?
c
d
e
f
g
c
d
e
f
g
f. Have you defaulted on any type of loan?
c
d
e
f
g
c
d
e
f
g
g. Have you had bills or debts turned over to a collection agency?
c
d
e
f
g
c
d
e
f
g
h. Have you had any account or credit card suspended, charged off, or cancelled for
failing to pay as agreed?
c
d
e
f
g
c
d
e
f
g
i. Have you been evicted for non-payment of financial obligations?
c
d
e
f
g
c
d
e
f
g
j. Have you been delinquent on court-imposed alimony or child support payments?
c
d
e
f
g
c
d
e
f
g
k. Have you had your wages, benefits, or assets garnished or attached for any
reason?
c
d
e
f
g
c
d
e
f
g
l. Have you violated the terms of agreement for a travel or credit card provided by
your employer?
c
d
e
f
g
c
d
e
f
g
m. Have you been over 180 days delinquent on any debt(s)?
c
d
e
f
g
c
d
e
f
g
n. Are you currently over 90 days delinquent on any debt(s)?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to any question above (a-n), provide the information requested
below for each positive response, indicating the corresponding question letter.
Summary of Occurrences
# Date of Occurrence Type of Occurrence
1 (~)/(~)
(~)
Add an Entry
Actions
Edit
Delete
Section 26: Financial Record · Section Summary
Page 2 of 2
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 26: Financial Record · Entry Details
Page 1 of 2
Go
Navigation: SF86 Section 26: Financial Record
Help · Display · Logout
Section 26: Financial Record
Entry Details
OMB No. 3206-0005
Form: SF86
Provide the information requested below.
Date of Occurrence
Month/Year
/
Est.
c
d
e
f
g
Indicate Corresponding Questions (Check all that apply)
a) Filed a petition under any chapter of the bankruptcy code.
c b) Had possessions or property voluntarily or involuntarily repossessed or foreclosed.
d
e
f
g
c c) Failed to pay Federal, state, or other taxes, or to file a tax return, when required by law or
d
e
f
g
ordinance.
c d) Had a lien placed against property for failing to pay taxes or other debts.
d
e
f
g
c e) Had a judgment entered against me.
d
e
f
g
c f) Defaulted on a loan.
d
e
f
g
c g) Had bills or debts turned over to a collection agency.
d
e
f
g
c h) Had an account or credit card suspended, charged off, or cancelled for failing to pay as
d
e
f
g
agreed.
c i) Evicted for non-payment of financial obligations.
d
e
f
g
c j) Delinquent on court-imposed alimony or child support payments.
d
e
f
g
c k) Had wages, benefits, or assets garnished or attached.
d
e
f
g
c l) Violated the terms of agreement for a travel or credit card provided by an employer.
d
e
f
g
c m) Been over 180 days delinquent on a debt.
d
e
f
g
c n) Currently over 90 days delinquent on a debt.
d
e
f
g
c
d
e
f
g
Amount or Property Value Involved
Name of Agency/Organization/Individual to Whom Debt is Owed
Account Number
c
d
e
f
g
Not Applicable
Name Action/Debt is Recorded Under
Section 26: Financial Record · Entry Details
Page 2 of 2
Status of Action or Debt
Court or Agency Handling Case
c
d
e
f
g
Not Applicable
Court/Agency Name
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 27: Use of Information Systems · Section Summary
Page 1 of 1
Go
Navigation: SF86 Section 27: Use of Information Systems
Help · Display · Logout
Section 27: Use of Information Systems
Section Summary
OMB No. 3206-0005
Form: SF86
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.
Answer the following questions.
#
Question
Yes No
a. In the last 7 years, have you illegally or without proper authorization entered into any
information technology system?
c
d
e
f
g
c
d
e
f
g
b. 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?
c
d
e
f
g
c
d
e
f
g
c. 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?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to any question above (a-c), provide an entry for each incident.
Summary of Incidents
# Date of Incident Location
1 (~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 27: Use of Information Systems · Entry Details
Page 1 of 1
Go
Navigation: SF86 Section 27: Use of Information Systems
Help · Display · Logout
Section 27: Use of Information Systems
Entry Details
OMB No. 3206-0005
Form: SF86
Date of Incident
Month/Year
/
Est.
c
d
e
f
g
Nature of Incident/Offense
Disposition
Location Incident Took Place
Name
Place
City:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Cancel
Reset this Screen
Version 2.00.00
Section 28: Involvement in Non-Criminal Court Actions · Section Summary
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 28: Involvement in Non-Criminal Court Actions
Section 28: Involvement in Non-Criminal Court
Actions
OMB No. 3206-0005
Form: SF86
Section Summary
Answer the following question.
Question
In the last 10 years, have you been a party to any public record civil court actions not
listed elsewhere on this form?
Yes No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes," provide an entry for each public record civil court action.
Summary of Public Record Civil Court Actions
# Date of Action Court
1 (~)/(~)
(~)
Actions
Edit
Delete
Add an Entry
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Section 28: Involvement in Non-Criminal Court Actions · Entry Details
Page 1 of 2
Navigation: SF86 Section 28: Involvement in Non-Criminal Court Actions
Help · Display · Logout
Section 28: Involvement in Non-Criminal Court
Actions
OMB No. 3206-0005
Form: SF86
Entry Details
Provide the information about the public record civil court action requested below.
Date of Action
Month/Year
/
Est.
c
d
e
f
g
Nature of Action
Result of Action
Name of Parties Involved
Court
Name
Street Address
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Go
Zip Code:
Country:
(List)
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Section 28: Involvement in Non-Criminal Court Actions · Entry Details
Save
Cancel
Page 2 of 2
Reset this Screen
Version 2.00.00
Section 29: Association Record · Comprehensive Details
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Section 29: Association Record
Section 29: Association Record
Comprehensive Details
OMB No. 3206-0005
Form: SF86
Answer the following questions.
#
Question
Yes No
a. Have you EVER been an officer or a member or made a contribution to an
organization dedicated to terrorism or the violent overthrow 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?
c
d
e
f
g
c
d
e
f
g
b. 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?
c
d
e
f
g
c
d
e
f
g
c. Have you EVER participated in militias (not including official state government
militias) or paramilitary groups?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes" to any of the questions above, explain.
Explanation
Additional Comments
Note: If you need to provide any additional comments about this information, enter them below.
Save
Reset this Screen
Version 2.00.00
Additional Comments · Any Additional Information You Would Like to Add
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Additional Comments
Additional Comments
Any Additional Information You Would Like to Add
OMB No. 3206-0005
Form: SF86
Use the space below to continue answers to all other items and to provide any information
you would like to add. Before each answer, identify the number of the item.
Additional Comments
Note: If you do not have any additional comments to provide, click "Save" to continue.
Save
Reset this Screen
Version 2.00.00
Certification · Certification Statement Preview
Help · Display · Logout
Page 1 of 1
Go
Navigation: SF86 Certification
OMB No. 3206-0005
Form: SF86
Certification
Certification Statement Preview
The following is a preview of the certification document you will sign when you complete
this investigation request.
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)
Date
(Do not sign at this time.)
Continue
Version 2.00.00
| File Type | application/pdf |
| File Title | http://localhost:8080/eqip-applicant/applicant/EditFormData/edi |
| File Modified | 2006-05-04 |
| File Created | 2006-05-04 |