Change Justification

Change Request Justification_v6_DMS[1].DOC

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

Change Justification

OMB: 3206-0005

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Change Request


This change request provides documentation of revisions made to the Standard Form (SF) 86 published in the Federal Register on June 1, 2006. Justification for the revisions are provided below.


SF 86 (Questionnaire for National Security Positions)


Purpose of this Form

Second paragraph: Rephrased, as suggested by the Defense Personnel Security Research Center (PERSEREC) via public comment.


Fifth paragraph: Deleted, as suggested by PERSEREC via public comment.


Authority to Request this Information

First paragraph: Deleted reference to Executive Order 12356, as suggested by the National Geospatial-Intelligence Agency (NGA) via public comment.


Second paragraph: Rephrased the paragraph on use of Social Security Numbers, as suggested by PERSEREC via public comment.


Your Personal Interview

Third paragraph: Restructured, as suggested by PERSEREC via public comment.


Special Instructions for Completing this Form

This section was revised by the Office of Personnel Management (OPM) after dialog with the Office of Management and Budget (OMB) as a result of suggestions from the United States (U.S. Army) and Department of Energy (DoE) Security received during the public comment period. The revised language is intended to make clear the scope of the investigation and the requirements for the Single Scope Background Investigation (SSBI).


Instructions for Completing this Form

1. Deleted sentence “Determine how many copies of the form you should submit.” This was suggested by the Internal Revenue Service (IRS) via public comment.


2. Replaced “Electronic Questionnaires for Investigations Processing (e-QIP), OPM’s web-based system application that houses an electronic version of this form.” with “the approved electronic format.” This was suggested by Aerospace Industries Association (AIA) via public comment.


3. Added “…unless otherwise noted.” This was suggested by PERSEREC via public comment.


4. Replaced “intent” with “consent” as a result of suggestions from PERSEREC and DOE Security via public comment.


5. “State codes” were renamed “Location codes”, for accuracy, as suggested by PERSEREC via public comment.


7. Revised to refer respondents to an automated system approved by the U.S. Postal Service to assist with Zip Codes, as opposed to asking the office that provided the form. This section was revised by OPM after dialog with OMB as a result of suggestions from the U.S. Army and DOE Security received during the public comment period.


9. The example of the date was changed, as suggested by PERSEREC via public comment, to an example using one of the first nine months in order to demonstrate the proper way to record a month with one digit (07 for July).


10. Added a reference to use of the Continuation Space on page 17 of the form to encourage full reporting of information, as suggested by the Department of the Navy (DON) Central Adjudicative Facility (CAF) via public comment.


Final Determination of your Eligibility

Replaced “you may” with “you will” in reference to being provided the opportunity personally to explain, refute, or clarify any information before a final decision is made, as suggested by DOE Security via public comment.


Penalties for Inaccurate or False Statements

Deleted a sentence because it is repetitive, as suggested by PERSEREC via public comment.


Privacy Act Routine Uses

Per OMB, the Privacy Act Routine Uses on the 1995 version of the Standard Forms will replace the Routine Uses published in the 30-day Federal Register Notice. (Routine Use number three was updated with the appropriate question numbers that correspond to the revised form.)


State Codes

This section was renamed Location Codes, for accuracy, as suggested by PERSEREC via public comment.


Certification

The Certification at the bottom of the Instructions was deleted, as suggested by DOE Security, IRS, AIA, and the National Security Agency (NSA), via public comment.


Agency Use Block

Block B: Revised to read “Extra coverage/Advance results” for accuracy.


Block K: Added “Other”, as suggested by U.S. Army and U.S. Investigative Services (USIS) via public comment; Added “e-OPF” to Web address.


Block M: Added “Other”, as suggested by U.S. Army and USIS via public comment.


Block O: Treasury accounting symbol (TAS) was added by Federal Investigative Services Division (FISD), OPM, at the request of our Business Management Group (BMG). TAS is a seven digit (or more) code assigned by the Department of the Treasury that identifies the agency, the period of availability of funds, and the specific account by fund group. Treasury is requiring this information be provided for IPAC billing when an agency enters into an interagency agreement with another agency.


Block P: Obligating document number was added by FISD, OPM, at the request of BMG. This is the document number of the purchase order or other obligating document prepared by the requesting agency.


Block Q: Business Event Type Code (BETC) was added by FISD, OPM, at the request of BMG. BETC is an eight character code that indicates the type of activity being reported (receipt, disbursement, etc.) BETC determines the transaction effect on the TAS’s fund balance with Treasury. BETC replaces transaction codes and subclasses, but at a more intuitive level of detail.


Block S: “Type of investigation” was changed to “Investigative requirement” for accuracy.


Block T: Added “email address”


Block U: “Processing official” was changed to “Secondary requesting official” for accuracy, as suggested by IRS via public comment. Also added “email address”.


Block V: “Investigation” was changed to “Applicant affiliation” for accuracy. The “affiliations” became FED CIV, MIL, CON, Other.


Statement: Added “Persons completing this form should begin with the questions below after carefully reading the foregoing instructions.” as suggested by AIA via public comment.


Question 5 – Other Names Used

Rephrased to become a Yes/No question to increase clarity and consistency, as suggested by USIS via public comment.


Instructions: “nee” was changed to “maiden” as suggested by PERSEREC via public comment.



Question 6 – Mother’s Maiden Name

Mother’s Birth Name” was changed to “Mother’s Maiden Name” (as on the 1995 version) as suggested via public comment.


Question 8 – Your Contact Information

Instructions added here as suggested by PERSEREC via public comment.


Night” was changed to “Evening” for consistency.


Question 9 – Citizenship

Added “Alien Registration Number” block as suggested by IRS, OMB, and PERSEREC via public comment.


Deleted “Expired?” block from the certificates, as they are not applicable, as suggested by DONCAF, DOE Security, U.S. Army, NGA, and Housing and Urban Development (HUD).


Question 9A – Documentation of U.S. Citizens Born Abroad

This section was changed from “State Department Form 240” to “Documentation of U.S. Citizens Born Abroad [STATE DEPARTMENT FORM (FS) 240, DS 1350, ETC.]” to cover the relevant documents as opposed to only the FS 240, as suggested by DONCAF and U.S. Army


In this section, we changed “Explanation” to “Document number” and added “Place of issuance” as suggested to OPM by the State Department.


Question 9B

Question 9B was split into 9B and 9C for easier completion by the respondent.


Question 9D – Immigration Status

Previously 9C


Changed “Place of entry” to “Place you entered the U.S.” for clarity.


Added “(I-94, etc.)” to “Type of document” for clarity.


Question 10 – Citizenship Information

Question 10B: Added “month/year” to “During what periods of time did you hold multiple citizenships?” as suggested OPM’s Suitability Adjudications Branch.


Question10C: Replaced “Why have you held multiple citizenships?” and “How were multiple citizenships obtained?” with “Is you non-U.S. citizenship based on your birth in a foreign country or the citizenship of your parents? (If “No,” explain.)” as suggested by the Defense Office of Hearings and Appeals (DOHA) via public comment.


Question 10D: Added “(If “Yes,” explain.)” to “Have you renounced or attempted to renounce your foreign citizenship(s)?” as suggested by U.S. Army and NGA via public comment.


Question 11 – Where You Have Lived

Instructions


Added “Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.” This was suggested by White House Counsel.


Replaced “All periods must be accounted for without breaks.” with “Residences for the entire 7 year period must be accounted for without breaks.” This was suggested by White House Counsel.


Replaced “Be sure to specify your location as closely as possible.” with “Be sure to be as specific as possible when listing and address location:” This was suggested by PERSEREC via public comment and supported by OMB.


Added “TDY” acronym to further clarify the information we are collecting, after dialog with OMB


We replaced “permanent address” with “address of record” to clarify, after dialog with OMB.


Added “…but you must list other part-time residences.” per dialog with OMB.


Replaced “…your actual physical address” with “…your actual physical location” as suggested by PERSEREC via public comment and after dialog with OMB.


Changed the scope from 5 years to 3 years, with regards to listing a person who knew you at the address, per the Investigative Standards.


Question text

Added “(Explain)” to “Other” option in the Status section, as suggested by AIA via public comment, and also to the Relationship section for consistency.


Added “at this address” to “Name of person who knows you” as suggested by DONCAF via public comment.






Question 12 – Where You Went to School

Instructions


Added “Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.” This was suggested by White House Counsel.


Added “all” for clarification after comment by SA Tech via public comment.


Replaced “If all of your education occurred more than 10 years ago, list your most recent Degree/Diploma including high school, no matter when that education occurred.” with “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.” This was for clarity as suggested by USIS and PERSEREC via public comment.


Changed the scope from 10 years to 3 years, with regards to listing a person who knew you at school, per the Investigative Standards, as suggested by Headquarters (HQ) DOE via public comment.


Completely” was replaced with “completed” as suggested by PERSEREC via public comment.


Degree/diploma received?” “If “Yes,” explain, include mm/yyyy awarded.” was replaced with “If “Yes,” identify type of degree/diploma received and date awarded.” as suggested by USIS, PERSEREC, AIA, and U.S. Army via public comment.


Name of person who knew you” was replaced by “Name of person who knows you” for consistency.


Question 12B was deleted because it is not necessary to ask the respondent for this information. Therefore, it is over-collecting.


Question 13 – Employment Activities

Instructions


Added “Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.” This was suggested by White House Counsel.


Revised text in various locations for clarification. Added “all”, “duty locations”, and “(TDY)” to the first two sentences.


Employer/Verifier Name” was changed to “Employer/Verifier Information” as suggested by HUD via public comment.


Contract” was changed to “company name” in the “Employer/Verifier Information” section as suggested by NSA, AIA, and U.S. Army via public comment.


Also in this section “these lines” was changed to “this block” as suggested by PERSEREC via public comment.


Employment Codes. During public comment, NGA suggested the codes be revised, prompting a review of the Employment codes. The Type of Employment codes in this section were replaced with the codes from the 1995 version of the form. It was determined by FISD that it is important to maintain these codes due to the historical data linked to them by our processing center. They were moved into the Instructions section and the check box options were removed. The Employment codes previously listed in this section were moved to Question 13C.


Question 13A – Employment/Unemployment Information

Employment Information” was replaced with “Employment/Unemployment Information” as suggested by PERSEREC via public comment.


Physical Location: “Your physical location” was replaced with “Your actual work address”, as suggested by PERSEREC and AIA via public comment.


Supervisor: Added “(if different from employer)” for clarity, as suggested by U.S. Army via public comment. Also added “Work” to address of supervisor as suggested by DONCAF, U.S. Army, and PERSEREC via public comment.


Question 13C – Employment Record

The codes from the Instructions of Question 13 were moved here. We coupled these codes with the question from the 1995 version of the form, with the addition of “Laid off from job by employer”.


In order to solicit the desired information to properly evaluate an individual’s employment history and any potential suitability or security issues related to it, a clear and separate question requiring a “yes/no” response is necessary, followed by an explanation of any positive response.  Without the separate “yes/no” question, an adverse employment separation could go undetected if the individual does not list a period of employment.  Establishing that this was done intentionally would be difficult to prove without a “yes/no” question.” 


Question 14 – Selective Service Record

Added “Please consult the SSS if you are unaware of your status before signing the form.” The revision was brought about by a comment made by HUD via public comment.


Question 15 – Military History

Instructions


Added “If you answer “No” to both 15a and 15b, go to Question 16.” as suggested by PERSEREC via public comment.


Question 15a: deleted “commissioned corps of the U.S. Public Health Service (PHS) or National Oceanic and Atmospheric Administration (NOAA)” because it is repetitive now that this information is collected in Question 13 resulting from the use of the 1995 version of the employment codes.


Question 15c: Added “to include date of discharge” as suggested by AIA via public comment.


Question 15d: Revised to reflect the language used on the 1995 version of the form “In the last 7 years (if an SSBI go back 10 years), have you been subject to court martial with 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).” This was prompted by a suggestion made by HUD via public comment.


Branch of Service Codes: National Guard was split into Air National Guard and Army National Guard. The National Guard has two important subdivisions: Air and Army. Air National Guard records are often not stored in the same place as Army National Guard records. The two branches are often separate (geography, record keeping, points of contact, etc.) and operate independently of each other. With this in mind, it would help the records repositories if we could eliminate the single code for National Guard, and instead have two codes: Army National Guard and Air National Guard. The respondent is able to select the proper division of the National Guard and we reprogram our systems to ensure the voucher is sent to the right location. This will greatly improve timeliness for this item.


Deleted “PHS” and “NOAA” because they are repetitive now that this information is collected in Question 13 resulting from the use of the 1995 version of the employment codes.


Discharge Codes: The discharge codes were revised to reflect current terms used by the Department of Defense (DOD), as suggested by DOHA, HQ DOE, via public comment. The addition of “Other (Explain)” was suggested by PERSEREC via public comment.


Service/Certificate Number” was replaced with “Service Number” as suggested by PERSEREC via public comment.


Question 16 – People Who Know You Well

Relationship to you: Added “(Check all that apply)” as suggested by PERSEREC via public comment.


Added “Explain” to the “Other” option for consistency.


Question 17 – Marital Status

Instructions: Added “If there is not a middle name, enter as “NMN”. as suggested by PERSEREC via public comment.


Question 17A – Current Spouse

State Department Form 240” was replaced with “FS 240 or 545” and “DS 1350” as suggested by U.S. Army via public comment.


Added “Explain” to the “Other” option for consistency.


Question 17C – Cohabitant

The definition of cohabitant was updated with the language used in the Investigator’s Handbook, as a result of a suggestion to further clarify made by PERSEREC via public comment.


State Department Form 240” was replaced with “FS 240 or 545” and “DS 1350” as suggested by U.S. Army via public comment.


Added “Explain” to the “Other” option for consistency.


Question 18 – Relatives

This entire section was reformatted into a linear layout, resulting from a suggestion made by DOE Security and U.S. Army via public comment. The Citizenship Information codes were removed and replaced with checkboxes. This format is more consistent with the rest of the form (Questions 9 and 17).


Country of Birth” was replaced with “Place of Birth” as it is more relevant, as suggested by DOE Security via public comment.


Question 19 – Foreign Contacts

This entire section was revised for clarity and formatted into a Yes/No question. Revisions were suggested by IRS, NSA, U.S. Army, and PERSEREC via public comment, with dialog with OMB.


Deleted “Approximate age” as this information is not relevant to the investigation.


Added “Country of residence” as suggested by U.S. Army via public comment.


Relationship to you: Added “(Check all that apply)” as suggested by PERSEREC via public comment.


Added “Explain” to the “Other” option for consistency.


Question 20 – Foreign Activities


Question 20A – Foreign Financial Interests

Added “Include stocks, personal property, company shares, investments, or ownership of corporate entities. Exclude U.S.-based fund managers and accounts managed through your employer.” as suggested by DOHA via public comment and as a result of dialog with OMB.


Question 20A.1: “Purpose” was changed to “Type of Financial Interest” as suggested by DOHA and USIS via public comment and also after dialog with OMB.


Question 20A.2: “Purpose” was changed to “Type of financial interest and name of party who controls it” as suggested by AIA and DOHA and also after dialog with OMB.


Question 20A.3: Added “and date(s) owned” to “Type of property” as suggested by U.S. Army via public comment.


Question 20A.4: New question, as suggested by PERSEREC and DONCAF via public comment. “Do you receive or have you received any educational, medical, retirement, social welfare, or other such benefits from a foreign country?” “Type of benefit” and “Estimated value in U.S. dollars”


Question 20B – Foreign Business, Professional Activities, and Foreign Government Contacts

Added “Respond for the time frame of the last 7 years, unless otherwise noted. Indicate if activity was on official U.S. Government business.” as suggested by the Department of Commerce via public comment.


Revised format for indicating “Official Government Business” per suggestion by DONCAF via public comment.


Question 20B.1: revised for clarity per suggestion by DOHA via public comment.


Question 20B.2: Added the word “any” per suggestion by DOHA and HUD via public comment.


Question 20B.3: Added “or any of your immediate family members” per suggestion by NSA via public comment. Also added “dates of request” to “consultation” per suggestion made by PERSEREC via public comment.


Question 20B.4: Added “or any of your immediate family members” per suggestion by NSA via public comment. Also revised to read “(embassies, consulates, agencies, or military services)” which was in part the suggestion of PERSEREC via public comment. The remainder of the question was revised by OPM after inquiry from OMB. Both agreed on the final language.


Questions 20B.6: Added “EVER” to holding a foreign passport, as suggested by White House Counsel.


Question 20C – Foreign Countries You Have Visited

This was made into a Yes/No question. (During public comment, SA Tech suggested that more questions be in a Yes/No format and we tried to accommodate when possible.)


Added “Do not list travel under official U.S. Government business, but you must include any personal trips made in conjunction with the official Government travel.” as suggested by HQ DOE, U.S. Army, and PERSEREC via public comment. Also the codes 2 and 3 were reversed as suggested by DOE Security via public comment.


Question 21 – Mental and Emotional Health

Deleted “…and did not involve the prescription of medication...” as suggested by DOHA via public comment.


Added “and/or counseling” language to the “If Yes” section and the chart to make it consistent with the question.


Deleted “Explain Circumstances of Treatment” from the chart because the information is irrelevant and it would be over-collecting.


Question 22 – Police Record

Instructions


Added “or the charge was dismissed.” as suggested by DOHA via public comment.


Revised the wording on instructions to read “For questions a and b, respond for the timeframe of the last 7 years (if an SSBI go back 10 years).” as suggested by DOE Security via public comment.


Question 22b: Deleted “detained” as the term is ambiguous.


Question 22 Chart: “Disposition” was replaced with “Action Taken” as suggested by PERSEREC via public comment.


Question 23 – Illegal Use of Drugs or Drug Activity

The tile was changed from “Use of Illegal Drugs and Drug Activity” was replaced with “Illegal Use of Drugs or Drug Activity” for consistency as suggested by DOE Security via public comment.


Question 23a: Deleted “Illegal” as suggested by DOHA via public comment.


Question 23b: Revised order of question for clarity, as suggested by DOHA via public comment.


Question 23d: Added to inquire about treatment or counseling for drug use. Additionally, “You will be asked to sign an additional release if information is needed concerning any treatment.” was also added. This information is relevant and is collected in Use of Alcohol. It should also be collected here.


Questions 24 – Use of Alcohol

Question 24a. Replaced “contacts” with “intervention” as suggested by DOHA via public comment.


Question 24b. This question was split into two questions (b and c) for clarity as suggested by DONCAF via public comment.


Question 25 – Investigations and Clearance Record

Question 25a. The Instructions for this question were simplified and “Unknown” codes added as suggested by White House Counsel. Also a “foreign country” code was added for Investigating Agency Codes and to Security Clearance Received, as suggested by DOE Security during public comment.


Added “Note: An administrative downgrade or termination of a security clearance is not a revocation.” This language is on the 1995 version and erroneously was not carried over to this revision. The addition of this phrase will prevent over-collection.


Question 25b. Added “To your knowledge” as suggested by U.S. Army via public comment. Also deleted “received a Statement of Reasons from an adjudicative facility” as suggested by a citizen during public comment.


Question 25c. Deleted, for over-collection, as suggested by AIA via public comment.


Question 26 – Financial Record

Question 26a. Added “If “Yes,” indicate Chapter 7, 11, or 13.” as suggested by U.S. Army via public comment.


Question 26l. “Have you violated the terms of agreement for a travel or credit card provided by your employer?” was replaced with “Have you been counseled, warned, or disciplined for violating terms of agreement for a travel or credit card provided by your employer?” after dialog with OMB as a result of a suggestion from Health and Human Services (HHS)


Added Question 26o: “Have you ever experienced financial problems due to gambling?” as suggested by PERSEREC via public comment.


Added Question 26p: “Are you currently delinquent on any Federal debt?” is a question on the OF 306 and was added to the SF 86 in order to prevent submission of the OF 306 with the investigation request. (The OF 306 is still part of the application process, but will no longer be submitted with the investigative request.) The discussions were the result of suggestions received from U.S. Army and DOE Security concerning the SF 85 via public comment.


Question 26 Chart: The chart was revised as suggested by U.S. Army via public comment.


Question 27 – Use of Information Technology Systems

The tile was changed from “Use of Information Systems” was replaced with “Use of Information Technology Systems”.


Question 27 Chart: “Disposition” was replaced with “Action Taken” as suggested by PERSEREC via public comment.


Question 28 – Involvement in Non-Criminal Court Actions

Added “(if an SSBI go back 10 years)”, as suggested by USIS via public comment.


Question 28 Chart: Revised “Name of Principal Parties Involved (if more space is needed, use Continuation Space on page 17)” in case more space is needed, as suggested by PERSEREC via public comment.


Question 29 – Association Record

Instructions: Added “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.” Question 29 on uses the term “terrorism” but does not define it.  Per our legal counsel, in order for the respondent to understand the term, we need to define what is meant by “terrorism,” otherwise it is facially ambiguous and may be challenged and stricken by a court as void for vagueness.  In addition, the definition of terrorism includes “criminal acts.”  Since we are asking for admissions of criminal activity, i.e., terrorism, we should grant use and derivative use immunity in the newly revised Question 29(b)(3).  See Kastigar v. United States, 406 U.S. 441, 453 (1972). 


Questions 29a and 29b were completely revised after legal review and are as follows:


(1)   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 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?

(2)   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 United States 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?

(3)   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 United States with the specific intent to further such unlawful activities?

(4)  Have you ever advocated any acts of terrorism or activities designed to overthrow the United States Government by force with the specific intent to incite others to unlawful action in furtherance of such aims?

(5)   Have you ever knowingly engaged in any activities designed to overthrow the United States Government by force?

(6)   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?


Continuation Space

Added “Use the continuation sheet(s) (SF 86A) for additional answers for items 11, 12, and 13.” as suggested by DOE Security via public comment.


Certification

Added “I have carefully read the foregoing instructions to complete this form.” to replace the certification deleted from the Instructions prompted by comments received from IRS and AIA.


General Release

Added “I also 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.” This was added because OPM and OMB have discussed the prospect of incorporating SSN verification into the background investigations process. In order to pursue this goal on all investigations, the SSA requires specific consent from contractor subjects. The suggested changes to the standard release, to include the addition of “Date of birth”, would permit OPM to attempt SSN verification on both federal and contract employees and applicants. The SSA informed OPM that the SSA cannot disclose data on contract employees/applicants without their consent because the action is not consistent with any published routine use of the information. Thus, SSA requires specific consent and this can be achieved through the suggested additions to the standard release. The verification of SSNs will assist OPM to ensure that name, date of birth and SSN, as recorded in the SSA’s master files, match the data within OPM’s record-keeping system.


Replaced “Copies” with “Photocopies” as suggested by PERSEREC via public comment.


HIPAA Release

Added “If you answered “Yes” to Question 21, carefully read this authorization to release information about you, then sign and date in ink.” for clarity.


Replaced “Copies” with “Photocopies” as suggested by PERSEREC via public comment.








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