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Instructions for Completing This Form
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OMB No. 3206-0005
Form: SF85P
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 Public Trust Positions (SF85P 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 to
establish that applicants or incumbents either employed by the Government or working for the
Government under contract are suitable for the job and/or eligible for a public trust position.
Giving us this information is voluntary. However, we may not be able to complete your investigation,
or complete it in a timely manner, if you don't give us each item of information we request. This may
affect your placement or employment prospects. Any information that you provide is evaluated
regarding its recency, seriousness, relevance to the position and duties, and in light of -- and in
relationship to -- all other information about you.
Withholding, misrepresenting, or falsifying information will have an impact on your employment
prospects, or job status, up to and including removal and debarment from Federal Service.
Authority to Request this Information
Depending upon the purpose of your investigation, the United States Government is authorized to
ask for this information under Executive Order 10450; sections 3301, 3302, and 9101 of title 5,
United States Code; and parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations.
Your Social Security Number (SSN) is needed to keep records accurate because other people may
have the same name and birth date. Disclosure of your SSN will be used to help identify you in
agency records. Although disclosure of your SSN is not mandatory, failure to disclose your SSN
may prevent or delay the processing of your background investigation. We may verify your SSN
with the Social Security Administration. The authority for soliciting and verifying your SSN is
Executive Order 9397.
The Investigative Process
Background investigations for public trust positions are conducted to develop information to show
whether you are reliable, trustworthy, of good conduct and character, and loyal to the United States.
The information that you provide on this form may be confirmed during the investigation. The
Form Completion Instructions · Instructions for Completing This Form
Page 2 of 5
investigation may extend beyond the time covered by this form when necessary to resolve issues.
Your current employer may be contacted as part of the investigation, even if you have previously
indicated on applications or other forms that you do not want your current employer to be contacted.
Your Personal Interview
Some investigations will include an interview with you as a routine part of the investigative process.
The investigator may ask you to further explain your answers to any question on this form. This
provides you the opportunity to update, clarify, and explain information on your form more
completely, which often helps to complete your investigation faster. It is important that the interview
be conducted as soon as possible after you are contacted. Postponements will delay the processing
of your investigation and declining to be interviewed may result in your investigation being delayed
or canceled.
For the interview, you will be asked to bring identification with your picture on it, such as a valid state
driver's license. There are other documents you may be asked to bring to verify your identity. These
may include documentation of any legal name change, Social Security card, passport, and/or your
birth certificate.
You may also be asked to bring documents about information you provided on the form or other
matters requiring specific attention. These matters include alien registration or naturalization
documentation; delinquent loans or taxes, bankruptcy, judgments, liens, or other financial
obligations; agreements involving child custody or support, alimony, or property settlements; arrests,
convictions, probation, and/or parole; or other matters described in court records.
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.
Form Completion Instructions · Instructions for Completing This Form
Page 3 of 5
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 public trust position is the responsibility of the Federal
agency that requested your investigation. You may be provided the opportunity personally to
explain, refute, or clarify any information before a final decision is made.
Penalties for Inaccurate or False Statements
The United States Criminal Code (title 18, section 1001) provides that knowingly falsifying or
concealing a material fact is a felony which may result in fines and/or up to 5 years of imprisonment.
In addition, Federal agencies generally fire or disqualify individuals who have materially and
deliberately falsified these forms, and this remains a part of the permanent record for future
placements. Your trustworthiness is a very important consideration in deciding your eligibility. Your
prospects of placement are better if you answer all questions truthfully and completely. You will
have adequate opportunity to explain any information you give us on the form and to make your
comments part of the record.
Disclosure of Information
The information you give us is for the purpose of determining your suitability for Federal
employment; we will protect it from unauthorized disclosure. The collection, maintenance, and
disclosure of background investigative information is governed by the Privacy Act. The agency that
requested the investigation and the agency that conducted the investigation have published notices
in the Federal Register describing the systems of records in which your records will be maintained.
The information on this form, and information collected during an investigation, may be disclosed
without your consent by an agency maintaining the information in a system of records as permitted
by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses published by the agency in the Federal
Register. The office that gave you this form will provide you a copy of its routine uses, if they are
different than those listed on this form.
PRIVACY ACT ROUTINE USES
OPM has published routine uses for disclosing background information in OPM's systems of
investigative records. OPM conducts the majority of background investigations and serves as the
lead agency for the SF 85P. OPM's routine uses follow:
z
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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
Form Completion Instructions · Instructions for Completing This Form
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to grant clearances to make a determination regarding access to classified information or
restricted areas, or to evaluate qualifications, suitability, or loyalty to the United States
Government, in connection with performance of a service to the Federal Government under a
contract or other agreement.
To the intelligence agencies of the Department of Defense, the National Security Agency, the
Central Intelligence Agency, and the Federal Bureau of Investigation for use in intelligence
activities.
To any source from which information is requested in the course of an investigation, to the
extent necessary to identify the individual, inform the source of the nature and purpose of the
investigation, and to identify the type of information requested.
To the appropriate Federal, State, local, tribal, foreign, or other public authority responsible for
investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order
where OPM becomes aware of an indication of a violation or potential violation of civil or
criminal law or regulation.
To an agency, office, or other establishment in the executive, legislative, or judicial branches
of the Federal Government, in response to its request, in connection with the hiring or
retention of an employee, the issuance of a security clearance, the conducting of a security or
suitability investigation of an individual, the classifying of jobs, the letting of a contract, or the
issuance of a license, grant, or other benefit by the requesting agency, to the extent that the
information is relevant and necessary to the requesting agency's decision on the matter.
To provide information to a congressional office from the record of an individual in response to
an inquiry from the congressional office made at the request of that individual. However, the
investigative file, or parts thereof, will only be released to a congressional office if OPM
receives a notarized authorization or signed statement under 28 U.S.C. 1746 from the subject
of the investigation.
To the Office of Management and Budget (OMB) at any stage in the legislative coordination
and clearance process in connection with private relief legislation as set forth in OMB Circular
No. A-19.
To disclose information to contractors, grantees, experts, consultants or volunteers performing
or working on a contract, service, or job for the Federal Government.
For Judicial/Administrative Proceedings--To disclose information to another Federal agency, to
a court, or a party in litigation before a court or in an administrative proceeding being
conducted by a Federal agency, when the Government is a party to the judicial or
administrative proceeding. In those cases where the Government is not a party to the
proceeding, records may be disclosed if a subpoena has been signed by a judge.
For National Archives and Records Administration--To disclose information to the National
Archives and Records Administration for use in records management inspections.
Within OPM for Statistical/Analytical Studies--By OPM in the production of summary
descriptive statistics and analytical studies in support of the function for which the records are
collected and maintained, or for related workforce studies. While published studies do not
contain individual identifiers, in some instances the selection of elements of data included in
the study may be structured in such a way as to make the data individually identifiable by
inference.
For Litigation--To disclose information to the Department of Justice, or in a proceeding before
a court, adjudicative body, or other administrative body before which OPM is authorized to
appear, when
(1) OPM, or any component thereof; or
(2) Any employee of OPM in his or her official capacity; or
(3) Any employee of OPM in his or her individual capacity where the Department of Justice or
OPM has agreed to represent the employee; or
(4) The United States, when OPM determines that litigation is likely to affect OPM or any of its
components; is a party to litigation or has an interest in such litigation, and the use of such
records by the Department of Justice or OPM is deemed by OPM to be relevant and
Form Completion Instructions · Instructions for Completing This Form
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Page 5 of 5
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 60 minutes, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street NW,
Washington, DC 20415. Do not send your completed form to this address, send it to the office that
provided you the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.
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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 60 minutes, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to OPM Forms Officer, U.S.
Office of Personnel Management, 1900 E Street NW, Washington, DC 20415. Do not send your completed
form to this address, send it to the office that provided you the form. The OMB clearance number, 3206-0005,
is currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.
Sections 1-7: Your Identifying Information · Comprehensive Details
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Sections 1-7: Your Identifying Information
Comprehensive Details
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OMB No. 3206-0005
Form: SF85P
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.
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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
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Not Applicable
#
Name
nee
Dates Used
Name
Name
IO/NFN/NMN
Dates Used
Last:
1.
Date
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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
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c Male
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Additional Comments
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Section 8: Contact Information · Comprehensive Details
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Section 8: Contact Information
Comprehensive Details
OMB No. 3206-0005
Form: SF85P
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
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Section 9: Citizenship · Comprehensive Details
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OMB No. 3206-0005
Form: SF85P
Section 9: Citizenship
Comprehensive Details
Mark the box that reflects your current citizenship status and follow its instructions.
Current Citizenship Status
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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)
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c I am a naturalized U.S. citizen. (Answer item 9B)
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c I am not a U.S. citizen. (Answer item 9C)
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U.S. Passport
Report information from your current or most recent U.S. Passport, if applicable.
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This information is not applicable to me.
Passport Number
Date Issued
Month/Day/Year
/
/
Est.
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Expired?
c Yes
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c No
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Item 9A
Report information from Form 240, if applicable.
State Department Form 240 (Report of Birth Abroad of a Citizen of the United States)
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This information is not applicable to me.
Date Form Was Completed
Section 9: Citizenship · Comprehensive Details
Month/Day/Year
/
/
Est.
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Explanation
Item 9B
Citizenship Certificate
Certificate Number
Date Issued
Month/Day/Year
/
/
Est.
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Expired?
g Yes
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c No
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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.
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Expired?
c Yes
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g No
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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.
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Type of Document
Document Number
Date Issued
Month/Day/Year
/
/
Est.
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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
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Section 10: Citizenship Information · Comprehensive Details
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Section 10: Citizenship Information
Comprehensive Details
OMB No. 3206-0005
Form: SF85P
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
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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
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g
c No
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Additional Comments
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Section 11: Where You Have Lived · Section Summary
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Section 11: Where You Have Lived
Section Summary
OMB No. 3206-0005
Form: SF85P
List the places where you have lived, beginning with your present residence and working
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
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Delete
Add an Entry
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Section 11: Where You Have Lived · Entry Details
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OMB No. 3206-0005
Form: SF85P
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
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c Rent
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c Military
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Housing
c Other
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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
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c Friend
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c Landlord
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c Business
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Associate
c Other
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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
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Section 12: Where You Went To School · Section Summary
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Section 12: Where You Went To School
Section Summary
OMB No. 3206-0005
Form: SF85P
Item 12A. School Information
List the schools you have attended, beginning with the most recent and working back 7
years. If all of your education occurred more than 7 years ago, list your most recent
Degree/Diploma including high school, no matter when that education occurred.
Summary of Where You Went To School
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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
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If you answered "Yes," explain. Do not include academic probations.
Suspension/Expulsion Explanation
Additional Comments
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Section 12: Where You Went To School · Entry Details
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Section 12: Where You Went To School
Entry Details
OMB No. 3206-0005
Form: SF85P
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
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School
c College/University/Military College
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c Vocational/Technical/Trade School
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c Correspondence/Distance/Extension/Online School
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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
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#
Not Applicable
Dates Awarded
Degree/Diploma/Other
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Section 12: Where You Went To School · Entry Details
Page 2 of 2
Date Awarded
Month/Year
1.
/
Est.
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Add A Blank Entry
Person Who Knew You
For schools you attended in the past 7 years, list a person who knew you at school
(instructor, student, etc.). Do not list people for education completely outside this 7-year
period.
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
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Section 13A/B: Employment Activities · Section Summary
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OMB No. 3206-0005
Form: SF85P
Section 13A/B: Employment Activities
Section Summary
Item 13A. Employment Information
List your employment activities, beginning with the present and working back 7 years. You
should list all full-time and part-time work, paid or unpaid, consulting/contracting work,
military service, temporary military duty locations over 90 days, self-employment, other
paid work, and all periods of unemployment. The entire period must be accounted for
without breaks. EXCEPTION: Do not list employments before your 18th birthday unless to
provide a minimum of 2 years of employment history.
Summary of Your Employment Activities
#
Time Period
Type of Employment
1 From (~)/(~) To (~)/(~) (None Selected)
Actions
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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 (~)/(~)
(~)
(~)
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Section 13A/B: Employment Activities · Select Employment Type
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Section 13A/B: Employment Activities
Select Employment Type
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OMB No. 3206-0005
Form: SF85P
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
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Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF85P
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
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Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF85P
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
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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
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Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF85P
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
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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
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Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF85P
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
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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
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Section 13A/B: Employment Activities
Employment Activity Details
OMB No. 3206-0005
Form: SF85P
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
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Section 13A/B: Employment Activities · Former Federal Service Details
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Section 13A/B: Employment Activities
Former Federal Service Details
OMB No. 3206-0005
Form: SF85P
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
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Section 13C: Employment Activities (Continued) · Section Summary
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Section 13C: Employment Activities (Continued)
Section Summary
OMB No. 3206-0005
Form: SF85P
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 (~)/(~)/(~)
(~)
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Section 13C: Employment Activities (Continued) · Entry Details
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Section 13C: Employment Activities (Continued)
Entry Details
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OMB No. 3206-0005
Form: SF85P
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
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Section 14: People Who Know You Well · Section Summary
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Section 14: People Who Know You Well
Section Summary
OMB No. 3206-0005
Form: SF85P
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 (~)/(~) (~)
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Section 14: People Who Know You Well
Entry Details
OMB No. 3206-0005
Form: SF85P
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
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Section 14: People Who Know You Well · Entry Details
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Section 15: Marital Status · Section Summary
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Section 15: Marital Status
Section Summary
OMB No. 3206-0005
Form: SF85P
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
Complete the following about your current spouse only.
Current Spouse
c
d
e
f
g
Not Applicable
Full Name Date Married
(~), (~) (~) (~)/(~)/(~)
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Section 15: Marital Status · Your Current Spouse
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OMB No. 3206-0005
Form: SF85P
Section 15: 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 15: 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 15: 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
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Section 15: Marital Status · Your Current Spouse
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Section 16: Relatives · Section Summary
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OMB No. 3206-0005
Form: SF85P
Section 16: Relatives
Section Summary
Give the full name, correct code, and other requested information for each of your relatives,
living or dead, specified below.
1.
2.
3.
4.
5.
6.
7.
Mother
Father
Stepmother
Stepfather
Foster Parent
Child (include adopted and foster)
Stepchild
Summary of Your Relatives
# Relationship Type Full Name
1 (None Selected)
(~), (~) (~)
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OMB No. 3206-0005
Form: SF85P
Section 16: Relatives
Entry Details
Relationship Type
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
Country of Birth
Country:
(List)
Country(ies) of Citizenship
#
Country
1.
(List)
Add A Blank Entry
Provide the following information if this person is living.
Current Address
Street:
City:
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Section 16: Relatives · Entry Details
Page 2 of 2
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:
Zip Code:
Country:
(List)
Additional Comments
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Section 17: Military History · Section Summary
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OMB No. 3206-0005
Form: SF85P
Section 17: 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)
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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 17: Military History · Section Summary
Page 2 of 2
Summary of Your Military Charges
#
Date Charged
Actions
1 From (~)/(~) To (~)/(~) Edit
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Section 17: Military History · Select Branch of Service
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Section 17: Military History
Select Branch of Service
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OMB No. 3206-0005
Form: SF85P
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
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Section 17: Military History · Service Details
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Section 17: 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
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OMB No. 3206-0005
Form: SF85P
Section 17: Military History · Service Details
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Section 17: Military History · Service Details
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Section 17: 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
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Section 17: Military History · Service Details
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Section 17: Military History · Service Details
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Section 17: 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
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Section 17: Military History · Service Details
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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
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Section 18: Selective Service Record · Comprehensive Details
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Section 18: Selective Service Record
Comprehensive Details
OMB No. 3206-0005
Form: SF85P
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
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Section 19: Investigations Record · Section Summary
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OMB No. 3206-0005
Form: SF85P
Section 19: 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
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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
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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 19: Investigations Record · Section Summary
# Month/Year Agency
1 (~)/(~)
(~)
Page 2 of 2
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Section 19: Investigations Record · Investigation Entry Details
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Section 19: Investigations Record
Investigation Entry Details
OMB No. 3206-0005
Form: SF85P
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
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Section 19: Investigations Record · Investigation Entry Details
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Section 19: Investigations Record · Clearance/Access Action Entry Details
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Section 19: Investigations Record
Clearance/Access Action Entry Details
OMB No. 3206-0005
Form: SF85P
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
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Section 19: Investigations Record · Withdrawal Entry Details
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Section 19: Investigations Record
Withdrawal Entry Details
OMB No. 3206-0005
Form: SF85P
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
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Section 20: Foreign Countries You Have Visited · Section Summary
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Section 20: Foreign Countries You Have Visited
Section Summary
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OMB No. 3206-0005
Form: SF85P
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
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Section 20: Foreign Countries You Have Visited · Entry Details
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Section 20: Foreign Countries You Have Visited
Entry Details
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OMB No. 3206-0005
Form: SF85P
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
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Section 20: Foreign Countries You Have Visited · Entry Details
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Section 21: Police Record · Section Summary
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OMB No. 3206-0005
Form: SF85P
Section 21: Police Record
Section Summary
Answer the following questions.
#
Question
Yes No
a. In the last 7 years, have you been arrested for, charged with, or convicted of any
offense(s)? (Omit traffic fines of less than $300.)
c
d
e
f
g
c
d
e
f
g
b. In the last 7 years, have you been imprisoned, on probation, or on parole?
c
d
e
f
g
c
d
e
f
g
c. Are you now under charges for any violation of the law?
c
d
e
f
g
c
d
e
f
g
d. In the last 7 years, have you been convicted by a military court martial? (If no
military service, answer "No".)
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 (~)/(~) (~)
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Section 21: Police Record · Entry Details
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OMB No. 3206-0005
Form: SF85P
Section 21: 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
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Section 21: Police Record · Entry Details
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Section 22: Use of Illegal Drugs and Drug Activity · Section Summary
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Section 22: Use of Illegal Drugs and Drug Activity
Section Summary
OMB No. 3206-0005
Form: SF85P
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 year, 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)?
c
d
e
f
g
c
d
e
f
g
b. 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-b), 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
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Section 22: Use of Illegal Drugs and Drug Activity · Entry Details
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Section 22: Use of Illegal Drugs and Drug Activity
Entry Details
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OMB No. 3206-0005
Form: SF85P
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
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Section 23: Financial Record · Section Summary
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Section 23: Financial Record
Section Summary
OMB No. 3206-0005
Form: SF85P
Answer the following question.
#
Question
Yes No
a. In the last 7 years, have you, or a company over which you exercised some control,
filed for bankruptcy, been declared bankrupt, been subject to a tax lien, or had legal
judgment rendered against you for a debt?
c
d
e
f
g
c
d
e
f
g
If you answered "Yes," provide the information requested below.
Summary of Occurrences
# Date of Action Type of Action
1 (~)/(~)
(~)
Actions
Edit
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Add an Entry
Answer the following question.
#
Question
b. Are you now over 180 days delinquent on any debt? Disclose all financial
obligations that apply, including those for which you are a cosigner or guarantor.
Yes No
c
d
e
f
g
c
d
e
f
g
If you answered "Yes," provide the information requested below.
Summary of Delinquencies
# Date Incurred Creditor/Obligee
1 (~)/(~)
(~)
Actions
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Section 23: Financial Record · Occurrence Entry Details
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OMB No. 3206-0005
Form: SF85P
Section 23: Financial Record
Occurrence Entry Details
Date of Initial Action
Month/Year
/
Est.
c
d
e
f
g
Type of Action
Name Action Occurred Under
Court or Agency Handling Case
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
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Section 23: Financial Record · Delinquency Entry Details
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OMB No. 3206-0005
Form: SF85P
Section 23: Financial Record
Delinquency Entry Details
Date Incurred
Month/Year
Est.
/
c
d
e
f
g
Type of Loan or Obligation
Account Number
c
d
e
f
g
Not Applicable
Creditor or Obligee
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
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Additional Comments · Any Additional Information You Would Like to Add
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Additional Comments
Any Additional Information You Would Like to Add
OMB No. 3206-0005
Form: SF85P
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
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Certification · Certification Statement Preview
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OMB No. 3206-0005
Form: SF85P
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 employment prospects or job status, up to and including my removal and
debarment from Federal service.
Signature (Sign in ink)
Date
(Do not sign at this time.)
Continue
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| File Type | application/pdf |
| File Title | http://localhost:8080/eqip-applicant/applicant/EditFormData/edi |
| File Modified | 2006-04-27 |
| File Created | 2006-04-27 |