SF 86 Revised 11-2007

SF86 11-16-07.pdf

Questionnaires and Supplemental Form for National Security, Public Trust, and Non-sensitive Positions

SF 86 Revised 11-2007

OMB: 3206-0005

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0005 can be found here:

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Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

Purpose of this Form
The United States (U.S.) 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. If you do not provide each item of
requested information, however, 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 on the basis of its
recency, seriousness, relevance to the position and duties, and consistency
with 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. It is imperative that the information provided
be true and accurate to the best of your knowledge.

You may also be asked to bring documents about information you provided on
the form or about other matters requiring specific attention. These matters
include (a) alien registration or naturalization documentation; (b) delinquent
loans or taxes, bankruptcies, judgments, liens, or other financial obligations;
(c) agreements involving child custody or support, alimony, or property
settlements; (d) arrests, convictions, probation, and/or parole; or (e) other
matters described in court records.

Special Instructions for Completing this Form
Questions on this form related to residence, employment, and education will
require 7 years of information except that Single-Scope Background
Investigations (SSBI) will require 10 years of information.
Provide 7 years of information unless you have been instructed to provide 10
years to satisfy SSBI requirements. If you are unsure as to the amount of
information to provide, contact the office that gave you this form.
The instructions for these questions specify a 10-year time frame when an
SSBI is required. If you have any questions about this investigative request
or 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.

Instructions for Completing this Form
1.

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

Type or legibly print your answers in ink (if the form is not legible, it will
not be accepted). You may also be asked to submit your form using the
approved electronic format.

All questions on this form must be answered. If no response is necessary
or applicable, indicate this on the form with "N/A" unless otherwise noted.

Any changes that you make to this form after you sign it must be initialed
and dated by you. Under certain limited circumstances, agencies may
modify your response(s) with your consent.

You must use the Location codes (abbreviations) listed on the back of this
page when you fill out this form. Do not abbreviate the names of cities or
foreign countries.

Whenever "City (Country)" is shown in an address block, also provide in
that block the name of the country when the address is outside the U.S.

The 5-digit postal Zip Codes are needed to speed the processing of your
investigation. Refer to an automated system approved by the U.S. Postal
Service to assist you with Zip Codes.

For telephone numbers in the U.S., be sure to include the area code.

All dates provided in this form must be in Month/Day/Year or Month/Year
format. Use numbers (01-12) to indicate months. For example, July 29,
1968, should be written as 07/29/1968. If you find that you cannot report
an exact date, approximate or estimate the date to the best of your ability
and indicate this by writing "APPROX." or "EST."

Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is
authorized to ask for this information under Executive Orders 10450, 10865,
12333, and 12968; sections 3301, 3302, and 9101 of title 5, U.S. Code
(U.S.C.); sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50,
U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal
Regulations.
Your Social Security Number (SSN) is needed to identify your unique records.
Although disclosure of your SSN is not mandatory, failure to disclose your
SSN may prevent or delay the processing of your background investigation.
The authority for soliciting and verifying your SSN is Executive Order 9397.

The Investigative Process
Background investigations for national security positions are conducted to
gather information to show whether you are reliable, trustworthy, of good
conduct and character, and loyal to the U.S. 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 your
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 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.

10. If you need additional space for explanation or to list your residences,
employment/self-employment/unemployment, or education, you should
use a continuation sheet, SF 86A. If additional space is needed to
answer other items, use the Continuation Space on page 17 or a blank
sheet(s) of paper. Each blank sheet of paper you use must contain your
name and SSN at the top of the page.

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

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

Penalties for Inaccurate or False Statements
The U.S. 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. 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 to us on this form and to make your comments part of the record.

DISCLOSURE INFORMATION
The information you give to 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 dislcosed 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
1. To the Department of Justice when: (a) the agency or any component
thereof; or (b) any employee of the agency in his or her official capacity; or (c)
any employee of the agency in his or her individual capacity where the
Department of Justice has agreed to represent the employee; or (d) the
United States Government, is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are
both relevant and necessary to the litigation and the use of such records by
the Department of Justice is therefore deemed by the agency to be for a
purpose that is compatible with the purpose for which the agency collected the
records.
2. To a court or adjudicative body in a proceeding when: (a) the agency or
any component thereof; or (b) any employee of the agency in his or her official
capacity; or (c) any employee of the agency in his or her individual capacity
where the Department of Justice has agreed to represent the employee; or (d)
the United States Government is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are
both relevant and necessary to the litigation and the use of such records is
therefore deemed by the agency to be for a purpose that is compatible with
the purpose for which the agency collected the records.
3. Except as noted in Question 23 and 27, when a record on its face, or in
conjunction with other records, indicates a violation or potential violation of
law, whether civil, criminal, or regulatory in nature, and whether arising by
general statute, particular program statute, regulation, rule, or order issued
pursuant thereto, the relevant records may be disclosed to the appropriate
Federal, foreign, State, local, tribal, or other public authority responsible for
enforcing, investigating or prosecuting such violation or charged with
enforcing or implementing the statute, rule, regulation, or order.
4. To any source or potential source from which information is requested in
the course of an investigation concerning the hiring or retention of an
employee or other personnel action, or the issuing or retention of a security
clearance, contract, grant, license, or other benefit, 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.

5. To a Federal, State, local, foreign, tribal, or other public authority the fact
that this system of records contains information relevant to the retention of an
employee, or the retention of a security clearance, contract, license, grant, or
other benefit. The other agency or licensing organization may then make a
request supported by written consent of the individual for the entire record if it
so chooses. No disclosure will be made unless the information has been
determined to be sufficiently reliable to support a referral to another office
within the agency or to another Federal agency for criminal, civil,
administrative, personnel, or regulatory action.
6. To contractors, grantees, experts, consultants, or volunteers when
necessary to perform a function or service related to this record for which they
have been engaged. Such recipients shall be required to comply with the
Privacy Act of 1974, as amended.
7. To the news media or the general public, factual information the disclosure
of which would be in the public interest and which would not constitute an
unwarranted invasion of personal privacy.
8. To a Federal, State, or local agency, or other appropriate entities or
individuals, or through established liaison channels to selected foreign
governments, in order to enable an intelligence agency to carry out its
responsibilities under the National Security Act of 1947 as amended, the CIA
Act of 1949 as amended, Executive Order 12333 or any successor order,
applicable national security directives, or classified implementing procedures
approved by the Attorney General and promulgated pursuant to such statutes,
orders or directives.
9. To a Memeber of Congress or to a Congressional staff member in
response to an inquiry of the Congressional office made at the written request
of the constituent about whom the record is maintained.
10. To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review
of private relief legislation.

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

AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA

Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland

HI
ID
IL
IN
IA
KS
KY
LA
ME
MD

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

MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ

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

NM
NY
NC
ND
OH
OK
OR
PA
RI
SC

American Samoa
Federated States of Micronesia

AS
FM

Guam
Marshall Islands

GU
MH

Northern Mariana Islands
Puerto Rico

MP
PR

Palau
Virgin Islands of the U.S.

PW
VI

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

SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

PUBLIC BURDEN INFORMATION
Public reporting burden for this collection of information is estimated to average 120 minutes per response, 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, N.W., 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.

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Codes

Investigating agency use only

Case number

AGENCY USE ONLY
A Type of investigation

B Extra coverage/Advance results
H Position code

G Geographic location

C Sensitivity level

D Access/Eligibility

E Nature of action code

J SON

I Position title

K Location of official personnel folder

At SON
e-OPF

L SOI

None
NPRC
M Location of security folder

None
NPI

N IPAC

O TAS

F Date of action

Zip Code

Other Other address/Web address of e-OPF

At SOI Other address
Other
P Obligating document number

R Accounting data and/or Agency case number

Zip Code
Q BETC
S Investigative requirement

Initial
Reinvestigation

T Requesting official - Name

Signature

Title

Email address

Date

Telephone number

U Secondary requesting official - Name

Title
Telephone number

Email address

V Applicant affiliation

CON
Other

FED CIV
MIL

PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING
THE FOREGOING INSTRUCTIONS.
1 FULL NAME

- If you have only initials in your name, use them and enter (I/O) after the initial(s). - If you have no middle name, enter "NMN."
- If you are a "Jr.," "Sr.," etc. enter this in the box after your middle name.

Last name

First name

3 PLACE OF BIRTH
City

2 DATE OF BIRTH

Middle name

Jr., II, etc.

4 SOCIAL SECURITY NO.
County

State

Country (if outside the U.S.)

5 OTHER NAMES USED Have you used any other names?
NO

YES

If "Yes," give other names used and the period of time you used them [for example: your maiden name, name(s) by a former marriage, former
name(s), alias(es), or nickname(s)]. If the other name is your maiden name, put "maiden" in front of it.

Name #1

Month/Year

Name #2

Month/Year

Name #3

Month/Year

Name #4

Month/Year

6 MOTHER'S MAIDEN NAME
Last name

First name

7 YOUR IDENTIFYING INFORMATION
Height (feet and inches) Weight (pounds) Hair color

Eye color

Middle name

Sex

Female

Male
8 YOUR CONTACT INFORMATION Check box(es) indicating when you can be reached at each phone number.
Home e-mail address
Work e-mail address
Home telephone number

Work telephone number
Day
Evening

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

Mobile telephone number
Day
Evening

Day
Evening

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

9 CITIZENSHIP Mark the box that reflects your current citizenship status and follow its instructions.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.

I am a naturalized U.S. citizen. Go to 9B or 9C
I am not a U.S. citizen. Go to 9D

I am a U.S. citizen or national by birth, born outside the U.S. Go to 9A

U.S. PASSPORT Current or most recent passport
Date issued
Number

Expired

ALIEN REGISTRATION NUMBER (if applicable)
Number

YES

NO
9A DOCUMENTATION OF U.S. CITIZENS BORN ABROAD [STATE DEPARTMENT FORM (FS) 240, DS 1350, FS 545, etc.] Report information, if applicable.
Place of issuance
Date form was completed Document number
9B CITIZENSHIP CERTIFICATE (if applicable)
Where was this certificate issued? City/Court

State

Certificate number

Date issued

9C NATURALIZATION CERTIFICATE (if applicable)
Where was this certificate issued? City/Court

State

Certificate number

Date issued

9D IMMIGRATION STATUS Place you entered the U.S.
City

State

Country(ies) of citizenship

Date of entry

Type of document (I-94, etc.)

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

Document number

YES
NO Go to Question 11
B During what periods of time did you hold multiple citizenships?

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

Month/Year

C Is your non-U.S. citizenship based on your birth in a foreign country or the citizenship of your parents? (If "No," explain.)
YES

NO, explain

D Have you renounced or attempted to renounce your foreign citizenship(s)? (If "Yes," explain.)
NO
YES, explain
11 WHERE YOU HAVE LIVED Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.
List the places where you have lived, beginning with your present residence (#1) and working back 7 years (if an SSBI go back 10 years). Residences for
the entire 7 year period must be accounted for without breaks. Indicate the actual physical location of your residence. Do not use a Post Office Box as
an address, and do not list a permanent address when you were actually living at a school address, etc. Be sure to be as specific as possible when listing
an address location: for example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations
(TDY) under 90 days (list your address of record instead), but you must list other part-time residences. Your actual physical location in addition to your APO/
FPO address is required for overseas assignments.
For any address in the last 3 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 3-year period, and do not list your spouse, former spouse, or other relatives. Also, for addresses in the last 3 years, if the address is
"General Delivery," a Rural or State Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet (SF
86A). Do not list residences before your 18th birthday unless to provide a minimum of 2 years of residence history.
Residence Information and Point of Contact for that Period of Residence
Own
#1 Month/Year To Month/Year
Military housing
Status
Rent
Other (Explain)
Present

Street address

Apt.#

APO/FPO address
State

City (Country)
Name of person who knows you at this address

Current address

Zip Code
Apt.#

APO/FPO address (if currently applicable)
City (Country)
Telephone number

State
Alternate contact number

Relationship

Enter your Social Security Number before going to the next page
Page 2

Neighbor
Friend

Landlord
Business associate

Zip Code

Other (Explain)

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

11 WHERE YOU HAVE LIVED (Continued)
#2 Month/Year To Month/Year
Status

Own

Military housing

Rent

Other (Explain)

Street address

Apt.#

APO/FPO address
State

City (Country)
Name of person who knows you at this address

Current address

Zip Code
Apt.#

APO/FPO address (if currently applicable)
State

City (Country)
Telephone number

Alternate contact number

#3 Month/Year To Month/Year Status

Own
Rent

Relationship
Military housing
Other (Explain)

Neighbor
Friend
Street address

Landlord

Zip Code

Other (Explain)

Business associate
Apt.#

APO/FPO address
State

City (Country)
Name of person who knows you at this address

Current address

Zip Code
Apt.#

APO/FPO address (if currently applicable)
City (Country)
Telephone number

State
Alternate contact number

#4 Month/Year To Month/Year

Status

Relationship

Neighbor
Friend

Own

Military housing Street address

Rent

Other (Explain)

Landlord

Zip Code

Other (Explain)

Business associate
Apt.#

APO/FPO address
City (Country)

State

Name of person who knows you at this address

Current address

Zip Code
Apt.#

APO/FPO address (if currently applicable)
City (Country)
Telephone number

State
Alternate contact number

Relationship

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

Neighbor
Friend

Landlord
Business associate

Zip Code

Other (Explain)

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

12 WHERE YOU WENT TO SCHOOL Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.
List all schools you have attended, beginning with the most recent (#1) working back 7 years (if an SSBI go back 10 years). List college or university degrees
and the dates they were received. If your most recent degree or diploma was received more than 7 years ago (10 years for an SSBI), list it below no matter
when it was received.
In the Code block, show the most appropriate code to describe your school.
1 - High School
3 - Vocational/Technical/Trade School
2 - College/University/Military College
4 - Correspondence/Distance/Extension/Online School
For Correspondence/Distance/Extension/Online School, provide the address where the records are maintained.
For schools you attended in the last 3 years, list a person who knew you at school (instructor, student, etc.).
Do not list people for education periods completed more than 3 years ago.
SCHOOL INFORMATION
#1 Month/Year To Month/Year

Code

Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.

Name of school

YES
NO

State

Street address and City (Country) of school
Name of person who knows you

Current address

Apt. #
State

City (Country)
#2 Month/Year To Month/Year Code

Zip Code

Telephone number
Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.

Name of school

YES
NO

Street address and City (Country) of school
Name of person who knows you

State
Current address

Apt. #
State

City (Country)
#3 Month/Year To Month/Year Code

Zip Code

Name of school

Telephone number
Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.

YES
NO

State

Street address and City (Country) of school
Name of person who knows you

#4 Month/Year To Month/Year

Apt. #

Current address
State

City (Country)
Code

Zip Code

Telephone number
Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.

Name of school

YES
NO

Street address and City (Country) of school
Name of person who knows you

State
Current address

#5 Month/Year To Month/Year Code

Apt. #
State

City (Country)

Zip Code

Telephone number
Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.

Name of school

YES
NO

Street address and City (Country) of school
Name of person who knows you
City (Country)

State
Current address

Zip Code
Apt. #

State

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

Zip Code

Telephone number

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

13 EMPLOYMENT ACTIVITIES Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.
List all your employment activities, beginning with the present (#1) and working back 7 years (if an SSBI go back 10 years). You should list all full-time and
part-time work, paid or unpaid, consulting/contracting work, all military service duty locations, temporary military duty locations (TDY) over 90 days, selfemployment, other paid work, and all periods of unemployment. The entire period must be accounted for without breaks. EXCEPTION: Do not list
employments that occurred before your 18th birthday unless it is necessary for providing a minimum of 2 years of employment history. If you require additional
space, use a continuation sheet (SF 86A).
Employer/Verifier Information. List the business name of your employer or the name of a person who can verify your self-employment or
unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You
should provide separate listings to reflect changes in your military duty locations or home ports. If you are a Federal Contractor, list company name,
not Federal agency.
Additional Periods of Activity. Complete this block if you worked for an employer on more than one occasion at the same physical location. After
entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the
additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and
information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of
employment on the lines below that information.
Employment Code: Use one of the codes listed below to identify the type of employment.
1 - Active military duty stations
2 - National Guard/Reserve
3 - U.S.P.H.S. Commissioned Corps

4 - Other Federal employment
5 - State Government (Non-Federal employment)
6 - Self-employment (include business name
and/or name of person who can verify)

7 - Unemployment (include name of verifier)
8 - Federal Contractor
9 - Other (explain)

13A EMPLOYMENT/UNEMPLOYMENT INFORMATION
#1 Dates of Employment
Type of Employment
Month/Year To Month/Year Employment code
Position title/Military rank
Present

Work hours Full-time
Part-time

Employer/Verifier
Telephone number

Name of employer/verifier
Address of employer/verifier
City (Country)

State

Physical Location
Your actual work address (if different from employer address)

Telephone number

City (Country)

State

Supervisor (if different from employer)
Name and title

Zip Code

Telephone number

Work address of supervisor
City (Country)

State

Additional Periods of Activity with this Employer
Month/Year To Month/Year Position title

Supervisor

Month/Year

Month/Year Position title

Supervisor

Month/Year

Month/Year Position title

Supervisor

Explanation/Reason for leaving

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

Zip Code

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued)
#2 Dates of Employment
Month/Year To Month/Year

Type of Employment
Employment code
Position title/Military rank

Work hours Full-time
Part-time

Employer/Verifier
Name of employer/verifier

Telephone number

Address of employer/verifier
City (Country)

State

Physical Location
Your actual work address (if different from employer address)

Telephone number

City (Country)

State

Supervisor (if different from employer)
Name and title

Telephone number

Zip Code

Work address of supervisor
State

City (Country)
Additional Periods of Activity with this Employer
Month/Year To Month/Year Position title

Supervisor

Month/Year

Month/Year Position title

Supervisor

Month/Year

Month/Year Position title

Supervisor

Zip Code

Explanation/Reason for leaving
#3 Dates of Employment
Month/Year To Month/Year

Type of Employment
Employment code
Position title/Military rank

Employer/Verifier
Name of employer/verifier

Work hours Full-time
Part-time
Telephone number

Address of employer/verifier
City (Country)

State

Physical Location
Your actual work address (if different from employer address)

Telephone number

City (Country)

State

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

Zip Code

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued)
Supervisor (if different from employer)
Name and title

Telephone number

Work address of supervisor

State

City (Country)

Additional Periods of Activity with this Employer
Month/Year To Month/Year Position title

Zip Code

Supervisor

Month/Year

Month/Year Position title

Supervisor

Month/Year

Month/Year Position title

Supervisor

Explanation/Reason for leaving

#4 Dates of Employment
Month/Year To Month/Year

Type of Employment
Employment code
Position title/Military rank

Work hours Full-time
Part-time

Employer/Verifier
Name of employer/verifier

Telephone number

Address of employer/verifier
City (Country)

State

Physical Location
Your actual work address (if different from employer address)

Telephone number

City (Country)

State

Supervisor (if different from employer)
Name and title

Telephone number

Zip Code

Work address of supervisor
State

City (Country)
Additional Periods of Activity with this Employer
Month/Year To Month/Year Position title

Supervisor

Month/Year

Position title

Supervisor

Month/Year

Month/Year Position title

Supervisor

Explanation/Reason for leaving

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

Zip Code

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

13B FORMER FEDERAL SERVICE, EXCLUDING MILITARY SERVICE, NOT INDICATED PREVIOUSLY (list below if applicable)
Dates of Federal Service
Agency/City (Country)/State/Zip Code
Month/Year To Month/Year
#1

Position Title

#2
#3

13C EMPLOYMENT RECORD
1. Has any of the following happened to you in the last 7 years? If "Yes," begin with the most recent occurrence and go backward, providing date
fired, quit, or left, and other information requested.

YES

Use the following codes and explain the reason your employment was ended.
1 - Fired from a job
2 - Quit a job after being
told you would be fired

3 - Left a job by mutual agreement following charges or allegations of misconduct
4 - Left a job by mutual agreement following notice of
unsatisfactory performance

Month/Year

Specify Reason

Code

5 - Left a job for other reasons under
unfavorable circumstances
6 - Laid off from job by employer

Employer's Name and Address (Include City/Country if outside U.S.)

State

Zip Code

YES

2. Have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace?
3. Have you received a written warning, been officially reprimanded, suspended, or disciplined for violating a security rule or policy?
If you answered "Yes," to 13C(2) and/or 13C(3), provide the name(s) of the employer(s), date(s) of incident(s), month/day/year of official action(s), location(s)
or facility(ies) of incident(s), and the nature of the violation(s) in the space below. If additional space is needed, use a blank sheet(s) of paper.

14 SELECTIVE SERVICE RECORD
a
b

Are you a male born after December 31, 1959? If "No," go to Question 15. If "Yes," go to b.
Have you registered with the Selective Service System (SSS)? If "Yes," provide your registration number below. If "No," explain the
reason for not registering below. Please consult the SSS if you are unaware of your status before signing this form.
Registration Number

Explanation

Enter your Social Security Number before going to the next page
Page 8

YES

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

15 MILITARY HISTORY Account for all of your military service through the questions below. If you answer "No" to both 15a and 15b, go to Question 16.

YES

a Have you EVER served in the U.S. military or the U.S. Merchant Marine?
b Have you EVER served in a foreign country's military, security forces, merchant marine, militia, or other defense forces?
c Have you EVER received a discharge that was not honorable?
d In the last 7 years (if an SSBI go back 10 years), have you been subject to court martial or other disciplinary proceedings under the Uniform
Code of Military Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and
outcome(s).

If you answered "Yes" to any question above, list all details of your military service below, starting with the most recent period of service and working back.
If you had a break in service, each separate time of service should be listed.
Code (Branch of Service): Use one of the codes listed below to identify your branch of service.
1 - Air Force
2 - Army

3 - Navy
4 - Marine Corps

7 - Air National Guard (NG)
8 - Army NG

5 - Coast Guard
6 - Merchant Marine

9 - Foreign military, defense, militia, security forces

O/E: Mark "O" block for Officer or "E" block for Enlisted, if applicable.
Status: "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an
"X": use the two-letter code for the state to mark the block.
Country: Identify the country for which you served.
Code (Type of Discharge): Use one of the codes listed below to indicate your separation status from your military service.
1 - Honorable

2 - Dishonorable

3 - Other Than Honorable

Branch of
Service Code Month/Year To Month/Year Service Number

4 - General

5 - Bad Conduct

Status
Active Active Inactive
Duty Reserve Reserve

6 - Other (Explain)
Type of
Discharge Code

Country
Air NG
State

Army NG
State

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

Home or work address

Reference name

Home or work address

Reference name

Home or work address

Relationship to you (Check all that apply)

Dates known
Month/Year To Month/Year

Apt. #

Schoolmate

State

Neighbor

Work associate

Friend

Schoolmate

City (Country)

Day

Zip Code

State

Neighbor

Work associate

Friend

Schoolmate

City (Country)

State

Evening

Alternate telephone no.

Telephone number

Other (Explain)
Day

Zip Code

Relationship to you (Check all that apply)

Dates known
Month/Year To Month/Year

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

Friend

Telephone number

Other (Explain)

Relationship to you (Check all that apply)

Dates known

Apt. #

Work associate

City (Country)

Month/Year To Month/Year

Apt. #

Neighbor

Evening

Alternate telephone no.

Telephone number

Other (Explain)
Day

Zip Code

Evening

Alternate telephone no.

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

17 MARITAL STATUS
Mark one box to show your current marital status and provide information about your spouse(s) or cohabitant below. If there is not a middle name, enter as
"NMN."
3 - Separated
1 - Never married
5 - Divorced
2 - Married (incl. Common Law)
6 - Widowed
4 - Annulled
17A CURRENT SPOUSE If applicable, complete the following about your current spouse only. If your current spouse was born outside the U.S., provide citizenship information.
Last name
Middle name
First name
Date of birth
Place of birth (include Country if outside the U.S.)
Social Security Number

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

Country(ies) of citizenship

Date married

Place married (City, include Country if outside the U.S.)

State

If separated, date of separation

State

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

Current address of spouse, if different than your current address (Street, City, include Country if outside the U.S.)

State

Zip Code

Telephone number

If spouse was born outside the U.S. indicate one type of documentation that he or she possesses and the document numbers.
FS 240 or 545
Citizenship certificate
Alien registration
Other (Explain)
U.S. Passport (current or most recent)
DS 1350
Naturalization certificate
Document number
Explain "Other"
17B FORMER SPOUSE(S)

Complete the following about your former spouse(s). Use blank sheets if needed.

Last name

Middle name

First name

Place of birth (include Country if outside the U.S.)
Date married

State

Date of birth

Country(ies) of citizenship
State

Place married (City, include Country if outside the U.S.)

Check one, then
give date

Divorced

Annulled Date

If divorced/annulled, where is the record located? City (Country) State

Widowed
Last known address of former spouse (Street, City, include Country if outside the U.S.)

State

Zip Code

Telephone number

17C COHABITANT [A cohabitant is a person with whom you share bonds of affection, obligation, or other commitment, as opposed to a person with whom you live for reasons of
convenience (a roommate)]. If applicable, complete the following about your cohabitant. If your cohabitant was born outside the U.S., provide citizenship information.

Last name
Social Security Number

First name

Middle name

Date of birth

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

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

Country(ies) of citizenship
If cohabitant was born outside the U.S., indicate one type of documentation that he or she possesses and the document numbers.
Citizenship certificate
Other (Explain)
FS 240 or 545
Alien registration
U.S. Passport (current or most recent)
Naturalization certificate
DS 1350
Document number
Explain "Other"

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

Date cohabitation began

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

18 RELATIVES
Relative Code - Use one of the following codes (1-16) listed below for each relative and give the full name and other requested information, if applicable, for
each of your relatives, living or deceased, specified below.
1 - Mother
5 - Foster parent
9 - Sister
13 - Half-sister
2 - Father
10 - Stepbrother
14 - Father-in-law
6 - Child (incl. adopted and foster)
3 - Stepmother
11 - Stepsister
15 - Mother-in-law
7 - Stepchild
4 - Stepfather
12 - Half-brother
16 - Guardian
8 - Brother
Code Full name
1

Deceased

Date of birth

Place of birth

Country(ies) of citizenship

Current address (Street, City, and State, include Country if outside the U.S.)
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Document number
FS 240 or 545
DS 1320
Alien registration
Other (Explain below)
U.S. Passport
Naturalization certificate
Citizenship certificate
Date of birth
Place of birth
Country(ies) of citizenship
Code Full name
Deceased
2
Current address (Street, City, and State, include Country if outside the U.S.)
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Other (Explain below)
Alien registration
Document number
FS 240 or 545
DS 1320
U.S. Passport
Naturalization certificate
Citizenship certificate
Code Full name

Deceased

Date of birth

Place of birth

Country(ies) of citizenship

Deceased

Date of birth

Place of birth

Country(ies) of citizenship

Deceased

Date of birth

Place of birth

Country(ies) of citizenship

Deceased

Date of birth

Place of birth

Country(ies) of citizenship

Deceased

Date of birth

Place of birth

Country(ies) of citizenship

Enter your Social Security Number before going to the next page
Page 11

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

19 FOREIGN CONTACTS
Do you have or have you had close and/or continuing contact with foreign nationals within the last 7 years with whom you, your spouse, or your cohabitant are
bound by affection, influence, and/or obligation? Include associates, as well as relatives, not already listed in Question 18. (A foreign national is defined as any
person who is not a citizen or national of the U.S.).
YES
NO
Dates known

1. Full name

Month/Year To Month/Year

Country(ies) of citizenship
Country of residence

Nature of relationship
Business
Other (Explain)

Personal

Type of contact (check all that apply)
Electronic correspondence
Telephone
Written correspondence
In person
Dates known

2. Full name

Month/Year To Month/Year

Number of contacts per year
Other (Explain)

1-2

3-7

8 - 15

More than 15

Country(ies) of citizenship
Country of residence

Nature of relationship
Business
Other (Explain)

Personal

Type of contact (check all that apply)
Electronic correspondence
Telephone
Written correspondence
In person
Dates known

3. Full name

Month/Year To Month/Year

Number of contacts per year
Other (Explain)

1-2

3-7

8 - 15

More than 15

Country(ies) of citizenship
Country of residence

Nature of relationship
Business
Other (Explain)

Personal

Type of contact (check all that apply)
Electronic correspondence
Telephone
Written correspondence
In person
Dates known

4. Full name

Month/Year To Month/Year

Number of contacts per year
Other (Explain)

1-2

3-7

8 - 15

More than 15

Country(ies) of citizenship
Country of residence

Nature of relationship
Business
Other (Explain)

Personal

Type of contact (check all that apply)
Electronic correspondence
Telephone
Written correspondence
In person
Dates known

5. Full name

Month/Year To Month/Year

Number of contacts per year
Other (Explain)

1-2

3-7

8 - 15

More than 15

Country(ies) of citizenship
Country of residence

Nature of relationship
Business
Other (Explain)

Personal

Type of contact (check all that apply)
Electronic correspondence
Telephone
Written correspondence
In person
Dates known

6. Full name

Month/Year To Month/Year

Number of contacts per year
Other (Explain)

1-2

3-7

8 - 15

More than 15

Country(ies) of citizenship
Country of residence

Nature of relationship
Business
Other (Explain)

Personal

20 FOREIGN ACTIVITIES

Type of contact (check all that apply)
Electronic correspondence
Telephone
Written correspondence
In person

Number of contacts per year
Other (Explain)

1-2

3-7

8 - 15

More than 15

Respond for the time frame of the last 7 years.

20A Foreign Financial Interests Include stocks, personal property, company shares, investments, or ownership of corporate entities.
Exclude U.S.-based fund managers and accounts managed through your employer.
Do you have or have you EVER had any foreign financial businesses, foreign bank accounts, or other foreign financial interests of
1.
which you have direct control or direct ownership?
Type of financial interest
Amount of funds in U.S. dollars

Do you have or have you had any foreign financial interests that someone controls on your behalf?
Type of financiaI interest and name of party who controls it

Do you own or have you owned real estate in a foreign country?
Type of property and date(s) owned

Amount of funds in U.S. dollars

Location of property

Estimated value of
property in U.S. dollars

Do you receive or have you received any educational, medical, retirement, social welfare, or other such benefits from a
foreign country?
Type of benefit
Estimated value in
U.S. dollars

Enter your Social Security Number before going to the next page
Page 12

YES

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

20B Foreign Business, Professional Activities, and Foreign Government Contacts Respond for the time frame of the last
7 years, unless otherwise noted. Indicate if activity was on official U.S. Government business.

YES

Official Govt.
Business

1. Have you provided advice or support to anyone associated with a foreign business or other foreign organization that you have
not previously listed as a former employer regarding any of the following: management, strategy, financing, or technology?
If "Yes" AND the activity was outside of official U.S. Government business, describe advice/support provided, name(s) of
foreign national and/or organization(s) to which it was provided, the name(s) of foreign country(ies), timeframe(s), and if
compensation was provided.

2. Have you attended any international conferences, trade shows, seminars, or other meetings outside of the U.S.?
If "Yes" AND the activity was outside of official U.S. Government business, provide locations, including the name(s) of foreign
country(ies), date(s), sponsoring organization(s), and purpose of event(s).
3. Have you or any of your immediate family members been asked to provide advice or serve as a consultant, even informally, by
any foreign government official or agency?
If "Yes" AND the activity was outside of official U.S. Government business, provide the date(s) of request and/or consultation(s),
including the name(s) of foreign country(ies), location of consultation(s), and circumstance(s).

4. Have you or any of your immediate family members had any contact with a foreign government, its establishment
(embassies, consulates, agencies, or military services), or its representatives, whether inside or outside the U.S.?
Answer "No" if the contact was for routine visa applications and border crossings related to either official U.S. Government travel
or foreign travel listed below in Question 20C. If contact was outside of official U.S. Government business, identify the foreign
government(s), establishment(s), and/or representative(s) involved and provide the circumstance(s), date(s), and location(s) of
contact(s).

5. Have you sponsored any foreign citizen to come to the U.S. as a student, for work, or for permanent residence?
If "Yes," provide the name of the foreign citizen(s) you sponsored, the country(ies) of citizenship, the date(s) of the foreign
citizen's stay in the U.S., their current address (if known), and the purpose of the foreign citizen's stay in the U.S.

6. Have you EVER held or do you now hold a passport that was issued by a foreign government?
If "Yes," provide the name(s), in which your foreign passport(s) was issued, the issuing country(ies), the passport number(s), the date(s) issued, the
expiration date(s), and the status of each.
20C Foreign Countries You Have Visited Respond for the time frame of the last 7 years.
Have you traveled outside the U.S. in the last 7 years?
YES
NO
Respond for foreign countries you have visited in the last 7 years, beginning with the most current and working back. If you have lived near a border and
have made short (one day or less) trips to the neighboring country (e.g. Canada or Mexico), you do not need to list each trip. Instead, provide the time
period, the code, the country, and a note ("Many Short Trips"). Do not list travel under official U.S. Government travel business, but you must include any
personal trips made in conjunction with the official U.S. Government travel.
5 - Visit family or friends
3 - Education
Use these codes to indicate the purpose(s) of your visit: 1 - Business/Professional conference
4 - Tourism
2 - Volunteer activities
6 - Other
Code Month/Year To Month/Year Number
Code Month/Year To Month/Year Number
Country
Country
of Days
of Days
#1

21 MENTAL AND EMOTIONAL HEALTH

YES

In the last 7 years, have you received treatment and/or counseling 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, not related to violence by you.
If you answered "Yes," indicate who conducted the treatment and/or counseling, provide the following information, and sign the Authorization for Release of
Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA).
Zip Code
Dates of Treatment and/or Counseling
State
Name/Address of Provider
Month/Year To Month/Year
#1
#2

Enter your Social Security Number before going to the next page
Page 13

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

22 POLICE RECORD
For this item, report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or the
charge was dismissed. 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.
For questions a and b, respond for the timeframe of the last 7 years (if an SSBI go back 10 years). Exclude any fines of less than $300 for
NO
YES
traffic offenses that do not involve alcohol or drugs.
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?
b Have you been arrested by any police officer, sheriff, marshal, or any other type of law enforcement officer?
c Have you EVER been charged with any felony offense? (Include those under Uniform Code of Military Justice.)
d

Have you EVER been charged with a firearms or explosives offense?

Have you EVER been charged with any offense(s) related to alcohol or drugs?
If you answered "Yes" to any question above, explain below, providing information for each and every offense.

Month/Year
#1

Law Enforcement Authority/Court

City and Country (if outside U.S.)

State

Zip Code

Offense

Action Taken

23 ILLEGAL USE OF DRUGS OR DRUG ACTIVITY
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your
failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information
derived from your responses will be used as evidence against you in any subsequent criminal proceeding.
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, Ecstacy, ketamine, etc.),
depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants (toluene, amyl nitrate,
etc.) or prescription drugs (including painkillers)? Use of a controlled substance includes injecting, snorting, inhaling, swallowing,
experimenting with or otherwise consuming any controlled substance.
b Have you EVER illegally used a controlled substance while possessing a security clearance; while employed as a law enforcement officer,
prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety?
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?

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 drugs? If you answered "Yes," provide date(s) of treatment and name(s) and address(es) of provider(s). You will
be asked to sign an additional release if information is needed concerning any treatment.

YES

If you answered "Yes" to a - d above, provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity.
Dates of Use/Activity
Type of Controlled Substance(s)
Explain (nature of use/activity, frequency of activity and number of times used)
Month/Year To Month/Year
#1

24 USE OF ALCOHOL Respond for the time frame of the last 7 years
a Has your use of alcohol had a negative impact on your work performance, your professional or personal relationships, your finances, or
resulted in intervention by law enforcement/public safety personnel? (If "Yes," explain.)

YES

Have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol?

Have you received counseling or treatment as a result of your use of alcohol?
If you answered "Yes" to question b or c above, provide the date(s) of treatment and the name(s) and address(es) of the counselor(s) or doctor(s)
below. Do not repeat information reported in response to Question 21. You will be asked to sign an additional release if information is needed
concerning any treatment.
Zip Code
State
Name/Address of Counselor or Doctor
Month/Year To Month/Year

#1
#2

Enter your Social Security Number before going to the next page
Page 14

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

25 INVESTIGATIONS AND CLEARANCE RECORD
a Has the U.S. Government or a foreign government EVER investigated your background and/or granted you a security clearance? If
"Yes," use the codes that follow to provide the requested information below. If "Yes," but you can't recall the investigating agency and/or
the security clearance received, enter the code for "Unknown." If your response is "No," or you don't know or can't recall if you were
investigated and cleared, check the "No" box.
Investigating Agency Codes
1 - Defense Department
5 - Treasury Department
2 - State Department
6 - Department of Homeland Security
3 - Office of Personnel
7 - Foreign government (Specify country)
Management
8 - Unknown
4 - Federal Bureau of
9 - Other (Explain below)
Investigation
Month/Year

Security Clearance Codes
0 - Not Required
1 - Confidential
2 - Secret
3 - Top Secret
4 - Sensitive Compartmented
Information
Foreign Government or Other Agency
(If necessary)

Agency
Code

YES

9 - Other (Explain below)
5-Q
6-L
7 - Issued by foreign
country (specify
country)
8 - Unknown
Clearance
Code

#1
#2
#3

YES

b To your knowledge, have you EVER had a clearance or access authorization denied, suspended, or revoked; or been debarred from
government employment? If "Yes," give the action(s), date(s) of action(s), agency(ies), and circumstances. Note: An administrative
downgrade or termination of a security clearance is not a revocation.
Month/Year

Department or Agency Taking Action

Circumstances

#1
#2
26 FINANCIAL RECORD
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, on the following page.
a

Have you filed a petition under any chapter of the bankruptcy code? If "Yes," indicate Chapter 7, 11, or 13.

Have you had any possessions or property voluntarily or involuntarily repossessed or foreclosed?

Have you failed to pay Federal, state, or other taxes, or to file a tax return, when required by law or ordinance?

Have you had a lien placed against your property for failing to pay taxes or other debts?

Have you had a judgment entered against you?

Have you defaulted on any type of loan?

Have you had bills or debts turned over to a collection agency?

Have you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed?

Have you been evicted for non-payment of financial obligations?

Have you been delinquent on court-imposed alimony or child support payments?

Have you had your wages, benefits, or assets garnished or attached for any reason?

Have you been counseled, warned, or disciplined for violating terms of agreement for a travel or credit card provided by your employer?

Have you been over 180 days delinquent on any debt(s)?

Are you currently over 90 days delinquent on any debt(s)?

Have you EVER experienced financial problems due to gambling?

Are you currently delinquent on any Federal debt?

Enter your Social Security Number before going to the next page
Page 15

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

26 FINANCIAL RECORD (Continued)
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. If you answered "Yes" on the previous page (a-p), provide the information requested below. For each "Yes" answer, provide
the corresponding letters.
Indicate
(a-p)

Date Satisfied
Month/Year

Amount of Property
Value Involved

Loan/Account Number/
Bankruptcy Type

Names of Agency/Organization/Individual to Whom Debt is/was Owed

#1
Name/Address of Company, Court, or Agency Handling Case
State
Zip Code
Indicate
(a-p)

Date Satisfied
Month/Year

Amount of Property
Value Involved

Loan/Account Number/
Bankruptcy Type

Name Action/Debt is Recorded Under

Status of Action or Debt

Names of Agency/Organization/Individual to Whom Debt is/was Owed

#2
Name/Address of Company, Court, or Agency Handling Case
State
Indicate
(a-p)

Date Satisfied
Month/Year

Amount of Property
Value Involved

Name Action/Debt is Recorded Under

Status of Action or Debt

Zip Code

Loan/Account Number/
Bankruptcy Type

Names of Agency/Organization/Individual to Whom Debt is/was Owed

#3
Name/Address of Company, Court, or Agency Handling Case
State
Indicate
(a-p)

Date Satisfied
Month/Year

Amount of Property
Value Involved

Name Action/Debt is Recorded Under

Status of Action or Debt

Zip Code

Loan/Account Number/
Bankruptcy Type

Names of Agency/Organization/Individual to Whom Debt is/was Owed

#4
Name/Address of Company, Court, or Agency Handling Case
State
Zip Code

Name Action/Debt is Recorded Under

Status of Action or Debt

27 USE OF INFORMATION TECHNOLOGY SYSTEMS
The following questions ask about your use of information technology systems. Information technology systems include all related computer
YES
hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage, or protection of
information. 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.
a

In the last 7 years, have you illegally or without proper authorization entered into any information technology system?

In the last 7 years, have you illegally or without authorization modified, destroyed, manipulated, or denied others access to information
residing on an information technology system?
In the last 7 years, have you introduced, removed, or used hardware, software, or media in connection with any information technology
system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations?

Date of Incident
(Month/Year)

Nature of Incident/Offense

Location Incident Took Place

#1
#2
#3
#4
#5
#6
#7

Enter your Social Security Number before going to the next page
Page 16

Action Taken

Standard Form 86
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

YES NO

28 INVOLVEMENT IN NON-CRIMINAL COURT ACTIONS
In the last 7 years (if an SSBI go back 10 years), have you been a party to any public record civil court action(s) not listed elsewhere on this form?
If you answered "Yes," provide the information about each public record civil court action(s) requested below.
Month/Year

Nature of Action

Result of Action

Name of Principal Parties Involved
(if more space is needed,
use Continuation Space on page 17)

Court Information
Court name

Street address
City

State

Zip Code

State

Zip Code

Court name

Street address
City

29 ASSOCIATION RECORD
The following questions pertain to your associations. 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. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or
are dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion, or to affect the conduct of a government by mass destruction, assassination or kidnapping.
a Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to terrorism, and which engaged in illegal YES NO
activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal
activities?
b

c
d

Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to the use of violence or force to
overthrow the U.S. Government, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication
to that end or with the specific intent to further such illegal activities?
Have you EVER been an officer or a member of, or made a contribution to, an organization that unlawfully advocates or practices the
commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the U.S.
with the specific intent to further such unlawful activities?
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force with the specific intent to
incite others to unlawful action in furtherance of such aims?

Have you EVER knowingly engaged in any activities designed to overthrow the U.S. Government by force?

Have you EVER knowingly engaged in any acts of terrorism? Neither your truthful response nor information derived from your response to
this question will be used as evidence against you in any subsequent criminal proceeding.

Have you EVER participated in militias (not including official state government militias) or paramilitary groups?
If you answered "Yes" to any of the questions above, explain below.

CONTINUATION SPACE
Use the continuation sheet(s) (SF 86A) for additional answers for items 11, 12, and 13. Use the space below to continue answers to all other items and to
provide any information you would like to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your
name and SSN. Before each answer, identify the number of the item and try to maintain question format.

After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate,
and then sign and date the following certification and the attached release(s).

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
have carefully read the foregoing instructions to complete this form. 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 may 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.
Date (mm/dd/yyyy)
Signature

Enter your Social Security Number before going to the next page
Page 17

Standard Form 86-1
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

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

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation, to obtain any information relating to my activities from individuals, schools,
residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection
agencies, retail business establishments, or other sources of information. This information may include, but is not limited to,
my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history record
information, and financial and credit information. I authorize the Federal agency conducting my investigation to disclose the
record of my background investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility for a national security position.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security
Number, and date of birth with information in SSA records and provide the results of the match) to the Office of Personnel
Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I
authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my
investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other
sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of
Investigation, the Department of Defense, the Department of State, and any other authorized Federal agency, to request
criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment
to, or retention in, a national security position, in accordance with 5 U.S.C. 9101. I understand that I may request a copy of
such records as may be available to me under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information upon request
of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless
of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by the Federal
Government only for the purposes provided in this Standard Form 86, and that it may be disclosed by the Government only as
authorized by law.
Photocopies of this authorization that show my signature are valid. This authorization is valid for five (5) years from the date
signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Read, sign, and date the release on the next page if you answered "Yes" to Question 21.

Full name (Type or print legibly)

Signature (Sign in ink)

Other names used
Current street address

Apt. #

City (Country)

Enter your Social Security Number before going to the next page

State

Date signed (mm/dd/yyyy)

Date of birth

Social Security Number

Zip Code

Home telephone number

Standard Form 86-2
Revised July 2007
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS

UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
If you answered "Yes" to Question 21, carefully read this authorization to release information about you, then sign and date it in ink.

Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) the questions below concerning your mental health
consultations. Your signature will allow the practitioner(s) to answer only these questions.
Authorization
I am seeking assignment to or retention in a national security position. As part of the clearance process, I hereby authorize
the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my
background investigation, to obtain the following information relating to my mental health consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to the U.S.
Office of Personnel Management. I understand that I may revoke this authorization except to the extent that action has
already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment,
payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
I understand the information disclosed pursuant to this release is for use by the Federal Government only for purposes
provided in the Standard Form 86 and that it may be disclosed by the Government only as authorized by law, but will no
longer be subject to the HIPAA privacy rule.
Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed
or upon termination of my affiliation with the Federal Government, whichever is sooner.

Full name (Type or print legibly)

Signature (Sign in ink)

Date signed (mm/dd/yyyy)

Social Security Number

Other names used
Current street address

Apt. #

City (Country)

State

Zip Code

Home telephone number

For Use By Practitioner(s) Only
Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to properly
safeguard classified national security information?
YES

If so, describe the nature of the condition and the extent and duration of the impairment or treatment.

What is the prognosis?

Signature (Sign in ink)

Practitioner name

Enter your Social Security Number before going to the next page

Date signed (mm/dd/yyyy)

File Type	application/pdf
File Modified	2007-11-16
File Created	2007-11-16