Form 1600-07 Background Investigation Questionnaire for Contractors

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OMB NUMBER: 3064-0072
EXPIRATION DATE: 8/31/2008

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE FOR CONTRACTORS
INSTRUCTIONS: Complete each item as it applies to your firm. (Please type or print.) An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number.
SECTION I - CONTRACTOR INFORMATION
1. NAME OF CONTRACTOR (Do not use acronyms unless applicable.)

2. FEDERAL TAX ID NUMBER

3. TRADE NAME (If different from contractor name)

4. TYPE OF BUSINESS

5. STREET ADDRESS (Include City, State, and ZIP Code)

6. SOLICITATION/CONTRACT NO. (If applicable)

7. CONTACT NAME

8. TELEPHONE NUMBER

SECTION II - JOINT VENTURE ENTITIES
9. NAME OF JOINT VENTURE (1)

10. FEDERAL TAX ID NUMBER

11. STREET ADDRESS (Include City, State, and ZIP Code)

12. CONTACT NAME

13. TELEPHONE NUMBER

14. NAME OF JOINT VENTURE (2)

15. FEDERAL TAX NUMBER

16. STREET ADDRESS (Include, City, State, and ZIP Code)

17. CONTACT NAME

18. TELEPHONE NUMBER

Check this box if information on additional entities has been attached to this form.

SECTION III - CERTIFICATION AND AUTHORIZATION
I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information and the information
provided to the FDIC regarding contracting with the FDIC in order to verify the contractor's fitness and integrity to provide services to or
on behalf of the Federal Deposit Insurance Corporation. The background investigation I am authorizing may require information
contained herein and acquired during the investigation to be disclosed to third parties, including credit-reporting businesses and State
and local licensing agencies. I hereby authorize and give my consent to such disclosures.
NOTE: Management official means any shareholder, employee, or partner who controls a company and any individual who directs the
day-to-day operations of a company. With respect to a partnership whose management committee or executive committee has
responsibility for the day-to-day operations of the partnership, management official means only a member of such committee but, if no
such committee exists, management official means each of the general partners. (12 U.S.C. § 366.2(I))
19. NAME OF MANAGEMENT OFFICIAL COMPLETING FORM (Type or print)

20. TITLE

21. SIGNATURE (Sign in Ink)

22. DATE

FDIC 1600/07 (10-05) Page 1

(See Page 2 for the Privacy Act Statement and Estimated Reporting Burden)

ESTIMATED REPORTING BURDEN
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance
Corporation, 550 17th Street, N.W., Washington, D.C. 20429; and to the Office of Management and Budget, Papework Reduction Project
(3064-0072), Washington, D.C> 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number.
PRIVACY ACT STATEMENT
Collection of this information is authorized by 12 U.S.C. §§ 1819, 1820(a), 1821, and 1822(f); Executive Order 9397; and 12 C.F.R. Part
366. The information requested on this form will be used by FDIC personnel to conduct background investigations of contractors
seeking to provide goods or services to the FDIC to determine whether the individual meets the FDIC fitness and integrity standards.
Specifically, the information provided may be disclosed to third parties, including credit-reporting businesses and State and local
licensing agencies, as necessary to conduct the background investigation authorized herein. Your Federal Tax Number [Social Security
Number (SSN)] is requested to further ensure record accuracy and to differentiate you among others with similar or identical names.
Disclosure of this information may also be made in accordance with the "routine uses of records" listed in the FDIC's Financial
Information Management Records, #30-64-0012, including disclosure to: the General Accounting Office for inspection by auditors;
appropriate Federal or State agencies for enforcement if a violation or possible violation of civil or criminal law is apparent; a court,
magistrate, or administrative tribunal when the FDIC is a party to the proceeding or has a significant interest in the proceeding; the U.S.
Office of Personnel Management and other appropriate agencies or offices to the extent disclosure is necessary to carry out
government-wide personnel management, investigatory, and adjudicatory functions; a congressional office in response to an inquiry
made at the request of the individual; the Internal Revenue Service, the Social Security Administration, State and local tax authorities;
the FDIC Office of the Inspector General for audit purposes; a consultant, person or entity who contracts or subcontracts with the FDIC,
to the extent necessary for the performance of the contract or subcontract; and to the Department of the Treasury, or another party for
the purpose of collecting or assisting in the collection of a delinquent debt owed to the FDIC. Completing this form is voluntary.
However, failure to provide all of the requested information (including your SSN) may delay or prevent the FDIC from conducting its
investigation, which may preclude you and your employer from consideration for the award of a contract.

FDIC 1600/07 (10-05) Page 2