revised SF 86 e-QIP screen shots (with navigation notes) based on the comments

Questionnaire for National Security Positions
OMB No. 3206–0005
Form: SF86

Interactive/Branching
Electronic Questionnaire

Revised Content
February 3, 2010

Based on Accepted 30-Day Notice Comments Received
Federal Register / Vol. 74, No. 188 / Wednesday, September 30, 2009 / Notices
OFFICE OF PERSONNEL MANAGEMENT
Submission for Review: Questionnaire for National Security Positions, SF 86

General Electronic Form Notes/Notices (All Sections):
The questions/content captured in this document are intended to display what data will
be captured from the subject and the questions to be presented based on the subject’s
responses during data capture.
Question numbering and “electronic form navigation notes” have been made throughout
this form to help facilitate review and navigation. These items are subject to change
based on the data collection or processing systems this form may be implemented in.
Additionally numbering and electronic form notes are not to be considered part of the
content of the form. Only the section numbers are applicable as the official numbering
for this form.
Screens may vary based on html style formatting, java scripting, data capture
formatting, system functionality, validation, and navigation. Systems that are used for
the collection of the “Questionnaire for National Security Positions (SF86)” data for
investigative purposes are subject to OMB review and approval.
Dropdown lists throughout this form (such as listings of countries, document types, etc.)
are subject to change based on changes or requirements of federal information
processing standards and other updates/changes to pertinent information collection,
consistent with approved content.

OMB No. 3206 0005
Standard Form 86
5 CFR Parts 731, 732, and 736

Questionnaire for National Security Positions
Follow instructions completely or your form will be unable to be processed. If you have any
questions, contact the office that provided you the form.
All questions on this form must be answered completely and truthfully in order that the
Government may make the determinations described below on a complete record. Penalties for
inaccurate or false statements are discussed below. If you are a current civilian employee of
the federal government: failure to answer any questions completely and truthfully could result
in an adverse personnel action against you, including loss of employment; with respect to
Sections 23, 27, and 29, however, neither your truthful responses nor information derived from
those responses will be used as evidence against you in a subsequent criminal proceeding.

Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting background
investigations, reinvestigations, and continuous evaluations of persons under consideration for,
or retention of, national security positions as defined in 5 CFR 732, and for individuals requiring
eligibility for access to classified information under Executive Order 12968. This form may also
be used by agencies in determining whether a subject performing work for, or on behalf of, the
Government under a contract should be deemed eligible for logical or physical access when the
nature of the work to be performed is sensitive and could bring about an adverse effect on the
national security.
Providing 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, eligibility for access to classified
information, or logical or physical access. It is imperative that the information provided be true
and accurate, to the best of your knowledge. Any information that you provide is evaluated on
the basis of its currency, seriousness, relevance to the position and duties, and consistency with
all other information about you. Withholding, misrepresenting, or falsifying information may
affect your eligibility for access to classified information, eligibility for a sensitive position, or
your ability to obtain or retain Federal or contract employment. In addition, withholding,
misrepresenting, or falsifying information may affect your eligibility for physical and logical
access to federally controlled facilities or information systems. Withholding, misrepresenting, or
falsifying information may also negatively affect your employment prospects and job status, and
the potential consequences include, but are not limited to, removal, debarment from Federal
service, loss of eligibility for access to classified information, or prosecution.
This form is a permanent document that may be used as the basis for future investigations,
eligibility determinations for access to classified information, or to hold a sensitive position,

suitability or fitness for Federal employment, fitness for contract employment, or eligibility for
physical and logical access to federally controlled facilities or information systems. Your
responses to this form may be compared with your responses to previous SF-86 questionnaires.
The investigation conducted on the basis of information provided on this form may be selected
for studies and analyses in support of evaluating and improving the effectiveness and efficiency
of the investigative and adjudicative methodologies. All study results released to the general
public will delete personal identifiers such as name, social security number, and date and place
of birth.

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, United States 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 (CFR).
Your Social Security Number (SSN) is needed to identify records unique to you. 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
determine 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, although you may
have previously indicated on applications or other forms that you do not want your current
employer to be contacted. If you have a security freeze on your consumer or credit report file,
then we may not be able to complete your investigation, which can adversely affect your
eligibility for a national security position. To avoid such delays, you should request that the
consumer reporting agencies lift the freeze in these instances.
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 demonstrate a
person is not reliable, trustworthy, or loyal. Federal agency records checks may be conducted on
your spouse, cohabitant(s), and immediate family members. After an eligibility determination
has been completed, you also may be subject to continuous evaluation, which may include
periodic reinvestigations, to determine whether retention in your position is clearly consistent
with the interests of national security.

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 assists in completing your investigation. It is imperative that the
interview be conducted immediately 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 required to provide photo identification, such as a valid state
driver's license. You may be required to provide other documents to verify your identity, as
instructed by your investigator. These documents may include certification of any legal name
change, Social Security card, passport, and/or your birth certificate. You may also be asked to
provide documents regarding information that you provide on this 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.

Instructions for Completing this Form (Electronic)
1. Follow the instructions provided to you by the office that gave you this form and any other
clarifying instructions, provided by that office, to assist you with 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.
2. All questions on this form must be answered. If no response is necessary or applicable,
indicate this on the form by checking the associated "Not Applicable" box, unless otherwise
noted.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply
a country name, you may select the country name by using the country dropdown feature.
4. When entering a U.S. address or location, select the state or territory from the "States"
dropdown list that will be provided. For locations outside of the U.S. and its territories, select the
country in the "Country" dropdown list and leave the "State" field blank.
5. Do not abbreviate the names of cities or foreign countries.
6. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to
an automated system approved by the U.S. Postal Service to assist you with Zip Codes.
7. For telephone numbers in the U.S., ensure that the area code is included.
8. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the
dropdown lists to select the month and day. The year should be entered as a four character

number ( i.e., 1978 or 2001.), or selected from a dropdown list. If you are unable to report an
exact date, approximate or estimate the date to the best of your ability, and indicate this by
checking the "Est." box.

*****Instructions for Completing this Form (Paper Form Only)*****
1. Follow the instructions, provided to you by the office that gave you this form and any other
clarifying instructions provided by that office to assist you with 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.
2. 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.
3. 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.
4. Any changes that you make to this form, after you sign it, must be initialed and dated by you.
Under extremely limited circumstances, agencies may modify your response(s) with your
consent.
5. 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.
6. Whenever "City (Country)" is indicated in an address block, also provide the name of the
country in that same block when the address is outside the U.S.
7. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to
an automated system approved by the U.S. Postal Service to assist you with Zip Codes.
8. For telephone numbers in the U.S., ensure that the area code is included.
9. 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 are unable to report an exact date, approximate or estimate the date to the best
of your ability, and indicate "APPROX." or "EST" in the field.
10. If additional space is required for an explanation or to list your residences, employment/selfemployment/unemployment, or education, you should use a continuation sheet, SF 86A.
If additional space is required to answer other items, use the Continuation Space on page 17, or a
blank sheet(s) of paper. Include your name and SSN at the top of each blank sheet (s) used.

** END INSTRUCTIONS FOR COMPLETING THIS FORM (PAPER FORM ONLY)**

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 and the agency that conducted your
investigation. You will be provided the opportunity to explain, refute, or clarify any information
before a final decision is made, if an unfavorable decision is considered. The United States
Government does not discriminate on the basis of race, color, religion, sex, national origin,
disability, or sexual orientation when granting access to classified information.

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 five (5) years 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 provide on this form and to make your comments
part of the record.

Disclosure Information
The information you provide is for the purpose of investigating you for a national security
position, and the information will be protected from unauthorized disclosure. The collection,
maintenance, and disclosure of background investigative information are 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 you provide on this form, and
information collected during an investigation, may be disclosed without your consent by an
agency maintaining the information in a system of records as permitted by the Privacy Act [5
U.S.C. 552a(b)], and by routine uses, a list of which are 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 Sections 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 Member 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 (PAPER FORM ONLY, Electronic forms to use dropdown lists)**
Alabama AL, Alaska AK, Arizona AZ, Arkansas AR, California CA, Colorado CO, Connecticut
CT, Delaware DE, District of Columbia DC, Florida FL, Georgia GA, Hawaii HI, Idaho ID,
Illinois IL, Indiana IN, Iowa IA, Kansas KS, Kentucky KY, Louisiana LA, Maine ME, Maryland
MD, Massachusetts MA, Michigan MI, Minnesota MN, Mississippi MS, Missouri MO, Montana
MT, Nebraska NE, Nevada NV, New Hampshire NH, New Jersey NJ, New Mexico NM, New
York NY, North Carolina NC, North Dakota ND, Ohio OH, Oklahoma OK, Oregon OR,
Pennsylvania PA, Rhode Island RI, South Carolina SC, South Dakota SD, Tennessee TN, Texas
TX, Utah UT, Vermont VT, Virginia VA, Washington WA, West Virginia WV, Wisconsin WI,
Wyoming WY American Samoa AS, Guam GU, Northern Mariana Islands MP, Puerto Rico PR,
Virgin Islands of the U.S. VI
*************END OF LOCATION CODES (PAPER FORM ONLY)**********

Public Burden Information (Electronic)
Public burden reporting for this collection of information is estimated to average 150 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. 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.
*************PUBLIC BURDEN INFORMATION (PAPER FORM ONLY)**********

Public Burden Information
Public burden reporting for this collection of information is estimated to average 150 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.
*********END OF PUBLIC BURDEN INFORMATION (PAPER FORM ONLY)**********

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER
CAREFULLY READING THE PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify
information on this form, I am subject to the penalties for inaccurate or false statement (per U. S.
Criminal Code, Title 18, section 1001), denial or revocation of a security clearance, and/or
removal and debarment from Federal Service.
□ Yes □ No

Save Reset this Screen

Electronic Form Navigation Note - If “No” At Save, fatal error stating that subject must read
instructions. If repeated subject to be taken from form entry to main menu. If “Yes”, Proceed
to Section 1.0.0.0

********* AFFIRMATION OF INSTRUCTIONS READ (PAPER FORM)*******
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE SECTIONS
BELOW AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify
information on this form, I am subject to the penalties for inaccurate or false statement (per U. S.
Criminal Code, Title 18, section 1001), denial or revocation of a security clearance, and/or
removal and debarment from Federal Service.
□ Yes □ No

Agency Use Block: “AUB”
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION
PROVIDED IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS
QUESTIONNAIRE, THOSE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR
ACTION.
FIPC Codes
Codes
A) Type of Investigation
Case Type
Service
B) Extra Coverage/Advance Results
(List) Codes
C) Sensitivity Level
Code
C) Computer/ADP
ADP
D) Access/Eligibility
Code
Comment
E) Nature of Action
Code
F) Date of Action
Month/Day/Ye
ar
G) Geographic Location
Code
H) Position Code
Code
I) Position title
Title

/

/

J) Submitting Office Number
SON
K) Location of Official Personnel Folder
Location
Other location (If "Other" selected)
Name

Street Address

Address
City

State

Zip Code

State

Zip Code

Web address
of e-OPF
(if "e-OPF"
selected)
L) Security Office Identifier
SOI
M) Location of Security Folder
Location
Other location (If "Other" selected)
Name

Street Address

Address
City

N) IPAC
Number
O) Treasury Account Symbol
TAS
P) Obligating document

Number
Q) Business Event Type
Code
R) Accounting Data and/or Agency Case Number
Data
S) Investigative Requirement
Type
T) Requesting Official
Name
Title
Email address
Telephone

Ext.

U) Secondary Requesting Official
Name
Title
Email address
Telephone

Ext.

V) Applicant Affiliation
Type
W) Deployment/PCS
(Do not provide deployment data if Classified or Sensitive information)
From:
To:

/

Est.

/

Permanent Relocation

Reason(s) for Temporary Duty Assignment or PCS

Location
(if imminent) Point of Contact at Location:
Street Address/Unit/
Duty Location:
City or Post Name:
Provide State or Country location.

Phone:

State:

Zip Code:

Country:

Agency Special Instructions for the Investigative Service Provider
Instructions

**************** AGENCY USE BLOCK “AUB” (PAPER FORM) ***************

Section 1-7 SF86 “Your Identifying Information and Contact
Information”
Note to Users – The old Section 6, mother’s maiden name, has been moved to
be part of section 18. The new section schema for sections 6-9 is as follows:
Section 6 = Identifying Information
7 = Contact Information
8 = Passport
9 = Citizenship

Section 1.0.0.0 - Full Name
Section 1: Full Name
1.0.0.1
Provide your full name. If you have only initials in your name, provide them and indicate
“Initial only”. If you do not have a middle name, indicate “No Middle Name” . If you are
a "Jr.," "Sr.," etc. enter this under Suffix.
Last name:
First name:
Middle name:
Suffix:
Add Optional Comment

Additional Comments
Provide additional comments about this information below.

Electronic Form Navigation Note *Entire Form* – Subject requires the opportunity
to add an Optional Comments. The “Add Optional Comment” button in this form
is placed on each screen to indicate by clicking the subject can provide
“Additional Comments” text box.
Save

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Electronic Form Navigation Note – At “Save” proceed to Section 2.0.0.0
Sections 1-8: Identifying Information

Section 2.0.0.0 - Date of Birth
Section 2: Date of Birth
Provide your date of birth.
2.0.0.1
Month/Day/Year
/

Est.

/

Add Optional Comment

Save

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Electronic Form Navigation Note – At “Save” proceed to Section 3.0.0.0

Sections 1-8: Identifying Information

Section 3.0.0.0 - Place of Birth
Section 3: Place of Birth
3.0.0.1
Provide your place of birth.
City:

County:

State:
Country:
Add Optional Comment

Save

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Electronic Form Navigation Note – At “Save” proceed to Section 4.0.0.0

Sections 1-8: Identifying Information

Section 4.0.0.0 – Social Security Number
Section 4: Social Security Number
Provide your U.S. Social Security Number.
4.0.0.1
Not Applicable
-

-

Add Optional Comment

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Sections 1-8: Identifying Information

Section 5.0.0.0 - Other Names Used - (Initial Question, no Entries provided)
Section 5: Other Names Used
Provide your other names used and the period of time you used them (for example: your
maiden name, name(s) by a former marriage (s), former name(s), alias(es), or
nickname(s)).
5.0.0.1
Have you used any other names?

□ Yes □ No

Add Optional Comment

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Electronic Form Navigation Note – If “Yes” proceed to Section 5.1.0.0, If “No”
proceed to Section 6.0.0.0

Sections 1-8: Identifying Information

Section 5.0.0.0 - Other Names Used – Summary – (Upon Completion of an
Entry)
Section 5: Other Names Used
Provide your other names used and the period of time you used them (for example: your
maiden name, name(s) by a former marriage (s), former name(s), alias(es), or
nickname(s)).

#

Time period

Name

Actions

1 From 03/2001 To Present Danger

Edit

Delete

2 From 02/1979 To 12/1999 Jim

Edit

Delete

5.0.0.1
Do you have additional names to enter?
□ Yes □ No
Add Optional Comment

Save

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Electronic Form Navigation Note – If “Yes” proceed to Section 5.1.0.0, If “No”
proceed to Section 6.0.0.0

Sections 1-8: Identifying Information

Section 5.1.0.0 - Other Names Used Detail
Section 5: Other Names Used
Detail
Provide your other name used and the period of time you used it [for example: your
maiden name, name by a former marriage, former name, alias, or nickname].
If you have only initials in your name, provide them and indicate “Initial only.” If you do
not have a middle name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.,"
etc. enter this under Suffix.
5.1.0.1
Provide other name used.
Last name:
First name:
Middle name:
Suffix:
5.1.0.2
Maiden name?
□ Yes
□ No
5.1.0.3
Provide dates used.
Date

Month/Year

From:

/

To:

/

Est./Pres.

5.1.0.4
Provide the reason(s) why the name changed.

Add Optional Comment

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Sections 1-8: Identifying Information

Electronic Form Navigation Note – At “Save” proceed to Section 5.0.0.0
Summary

Sections 1-8: Identifying Information

Section 6.0.0.0 - Your Identifying Information
Section 6: Your Identifying Information
Provide your identifying information.
6.0.0.1
Height: (feet)
(inches)
6.0.0.2
Weight:(in pounds)
6.0.0.3
Hair color:
6.0.0.4
Eye color:
6.0.0.5
Sex:

Female
Male

Add Optional Comment

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Sections 1-8: Identifying Information

Section 7.0.0.0 - Your Contact Information
Section 7: Your Contact Information
Provide your contact information.
7.0.0.1
Home e-mail address:
7.0.0.2
Work e-mail address:
7.0.0.3
Home telephone number:
(

Check box if International)
Number
Extension

Time
Day

7.0.0.4
Work telephone number
(

Check box if International)
Number
Extension

Time
Evening

7.0.0.5
Mobile/Cell telephone number
(

Check box if International)
Number
Extension

Time
Both

Add Optional Comment

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Sections 1-8: Identifying Information

Section 8: SF86 “U.S. Passport Information”
Section 8.0.0.0 – U.S. Passport Information
Section 8: U.S. Passport Information
8.0.0.1
Do you possess a U.S. passport (current or expired)?
□ Yes
□ No
Click HERE for U.S. State Department passport help.
http://travel.state.gov/passport
Add Optional Comment

Save

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Electronic Form Navigation Note – Yes Response proceed to Section 8.1.0.0, No
response proceed to Section 9.0.0.0.

Section 8: U.S. Passport Information

Section 8.1.0.0 – U.S. Passport Data
Section 8: U.S. Passport Information
Detail
Provide the following information for the most recent U.S. passport you currently
possess:
8.1.0.1
Provide your U.S. passport number.

Click HERE for U.S. State Department passport help.
http://travel.state.gov/passport
8.1.0.2
Provide the issue date of passport.
Month/Day/Year
Est.
/

/

8.1.0.3
Provide the expiration date of passport.
Month/Day/Year
Est.
/

/

8.1.0.4
Provide the name in which passport was first issued.
Last Name:
First Name:
Middle Name:
Suffix:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At Save proceed Section 9.0.0.0 “Citizenship
Information”

Section 8: U.S. Passport Information

Section 9 SF86 “Citizenship”
Section 9.0.0.0 – Citizenship
Section 9: Citizenship
Select the box that reflects your current citizenship status and click Save.
9.0.0.1
Provide your current citizenship status:
□ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.
□ I am a naturalized U.S. citizen.
□ I am not a U.S. citizen.
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – Subject will answer one of the above
selections and click Save.
If the applicant answers “U.S. Citizen by Birth in U.S.,” they will be directed to
Section 10.0.0.0
If the applicant answers “U.S. Citizen by birth in a foreign country” they will be
directed to Section 9.1.0.0.
If the applicant answers “Naturalized U.S. citizen” they will be directed to Section
9.2.0.0.
If the applicant answers “Not a U.S. Citizen” they will be directed to Section
9.3.0.0.

Section 9: Citizenship

Section 9.1.0.0 – U.S. Citizen, Foreign Born to U.S. Parents
Section 9: Citizenship
Foreign Born to U.S. Parents
You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a
foreign country.
9.1.0.1
Provide type of documentation of U.S. citizen born abroad.

Electronic Form Navigation Note – Contents of drop-down:
(FS) 240
DS 1350
FS545
Other (Provide explanation)
Explanation:

9.1.0.2
Provide document number for U.S. citizen born abroad:

9.1.0.3
Provide the date the document was issued.
Month/Day/Year
Est.
/

/

9.1.0.4
Provide the place of issuance.
City:
Provide Country if outside the United States; otherwise, provide State.
State:
Country:
9.1.0.5
Provide the name in which document was issued.
Last Name:

Speller

First Name:

Jennifer- Jo

MiddleName:

No Middle Name

Suffix:
Section 9: Citizenship

9.1.0.6
Provide your citizenship certificate number.

9.1.0.7
Provide the place of issuance.
City:
State:
Court:
9.1.0.8
Provide the date the certificate was issued.
Month/Day/Year
Est.
/

/

9.1.0.9
Provide the name in which the certificate was issued.
Last Name:

Speller

First Name:

Jennifer- Jo

Middle Name:

No Middle Name

Suffix:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 9.1.1.0

Section 9: Citizenship

Section 9.1.1.0 – U.S. Citizen, Foreign Born to U.S. Parents
Section 9: Citizenship
Foreign Born to U.S. Parents – U.S. Military Installation
9.1.1.1
Were you born on a U.S. military installation?
□ Yes
□ No

Add Optional Comment

Save

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Electronic Form Navigation Note – If “Yes” proceed to Section 9.1.2.0, if “No”
proceed to Section 10.0.0.0

Section 9: Citizenship

Section 9.1.2.0 – U.S. Citizen, Foreign Born to U.S. Parents, Base Location
Section 9: Citizenship
Foreign Born to U.S. Parents – U.S. Military Installation Detail
You answered that you were born on a U.S. military installation.
9.1.2.1
Provide the name of the base.

Add Optional Comment

Save

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Electronic Form Navigation Note – At “Save” proceed to Section 10.0.0.0.

Section 9: Citizenship

Section 9.2.0.0 – U.S. Citizen, Naturalization
Section 9: Citizenship
Naturalized U.S. Citizen
You answered that you are a naturalized U.S. citizen.
9.2.0.1
Provide the date of entry into the U.S.
Month/Day/Year
Est.
/

/

9.2.0.2
Provide the location of entry into the U.S.
City:
State:
9.2.0.3
Provide country(ies) of prior citizenship.
#
Country
Actions
1.

Delete

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 9.2.1.0

Section 9: Citizenship

Section 9.2.1.0 – U.S. Citizen, Naturalization
Section 9: Citizenship
Naturalized U.S. Citizen – Alien Registration Number
9.2.1.1
Do/did you have an U.S. alien registration number?
□ Yes
□ No
Add Optional Comment

Save

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Electronic Form Navigation Note – If “Yes” proceed to section 9.2.2.0, if “No”
proceed to section 9.2.3.0

Section 9: Citizenship

Section 9.2.2.0 – U.S. Citizen, Naturalization
Section 9: Citizenship
Naturalized U.S. Citizen – Alien Registration Number Detail
9.2.2.1
Provide your U.S. alien registration number.

Add Optional Comment

Save

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Electronic Form Navigation Note – At “Save” proceed to section 9.2.3.0

Section 9: Citizenship

Section 9.2.3.0 – U.S. Citizen, Naturalization
Section 9: Citizenship
Naturalized U.S. Citizen
9.2.3.1
Provide your citizenship certificate number.

9.2.3.2
Will be updated to validated drop-down list of courts
Provide the location of the court where the citizenship certificate was issued.
City:
State:
Court:
9.2.3.3
Provide the date the citizenship certificate was issued.
Month/Day/Year
Est.
/

/

9.2.3.4
Provide the name in which the citizenship certificate was issued.
Last Name:

Speller

First Name:

Jennifer- Jo

Middle Name:

No Middle Name

Suffix:
9.2.3.5
Provide your naturalization certificate number.

9.2.3.6
Will be updated to validated drop-down list of courts
Provide the location of the court where naturalization certificate was issued.
City:
State:
Court:

Section 9: Citizenship

9.2.3.7
Provide the date the naturalization certificate was issued.
Month/Day/Year
Est.
/

/

9.2.3.8
Provide the name in which the naturalization certificate was issued.
Last Name:

Speller

First Name:

Jennifer- Jo

Middle Name:

No Middle Name

Suffix:
9.2.3.9
Provide the basis of naturalization.

Electronic Form Navigation Note – Contents of Drop-Down:
- Based on my own individual naturalization application.
- By operation of law through my U.S. citizen parent.
- Other (Provide explanation)
Explanation:

Add Optional Comment

Save

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Electronic Form Navigation Note – At “Save” proceed to Section 10.0.0.0

Section 9: Citizenship

Section 9.3.0.0 - Not a U.S. Citizen
Section 9: Citizenship
Not a U.S. citizen
9.3.0.1
Provide your residence status.

9.3.0.2
Provide your date of entry in the U.S.
Month/Day/Year
Est.
/

/

9.3.0.3
Provide your place of entry in the U.S.
City:
State:
9.3.0.4
Provide your alien registration number.

9.3.0.5
Provide type of document issued. (I-94, etc.)

Electronic Form Navigation Note – Dropdown contains:
- I-94
- U.S. Visa
- Other (Provide explanation)
Explanation:

9.3.0.6
Provide document number:

Section 9: Citizenship

9.3.0.7
Provide the name in which the document was issued.
Last Name:

Speller

First Name:

Jennifer- Jo

Middle Name:

No Middle Name

Suffix:
9.3.0.8
Provide the date document was issued.
Month/Day/Year
Est.
/

/

9.3.0.9
Provide the expiration date of visa.
Month/Day/Year
Est.
/

/

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –At “Save” proceed to Section 10.0.0.0

Section 9: Citizenship

Section 10 SF86 “Citizenship &
Foreign Passport Information”
Section 10.0.0.0 Citizenship Information – Initial Screen
Section 10: Dual/Multiple Citizenship & Foreign Passport Information
10.0.0.1
Do you now or have you EVER held dual/multiple citizenships?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes proceed to section 10.1.0.0. If no
proceed to section 10.2.0.0.

Section 10: Citizenship Information

Section 10.0.0.0 Citizenship Information – Summary Screen
Section 10: Dual/Multiple Citizenship & Foreign Passport Information
Summary of dual/multiple citizenships you have listed:
#
Country
From
To
Actions
1. Mexico

10/2/1977

Present

Edit

Delete

2. Italy

9/22/1987

1/1/2002

Edit

Delete

10.0.0.2
Do you have an additional citizenship to provide?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – Loop through branching questions until
10.0.0.2 is answered “No”, then proceed to section 10.2.0.0 Foreign Passport.

Section 10: Citizenship Information

Section 10.1.0.0 - Country of Citizenship – EVER
Section 10: Dual/Multiple Citizenship & Foreign Passport Information Detail
You answered “Yes” to having EVER held dual/multiple citizenship, answer the
following:
10.1.0.1
Provide country of citizenship
Country:
During what period of time did you hold citizenship with this country?
10.1.0.2
Provide the date range that you held this citizenship, beginning with the date it was
acquired through its termination or “Present,” whichever is appropriate.
Date

Month/Year

From:

/

To:

/

Est./Pres.

10.1.0.3
How did you acquire this non-U.S. citizenship you now have or previously had?

Add Optional Comment

Save

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Electronic Form Navigation Note – At save proceed to 10.1.0.0.

Section 10: Citizenship Information

Section 10.1.1.0 - Country of Citizenship – Renounce Entry
Section 10: Dual/Multiple Citizenship & Foreign Passport Information Detail
10.1.1.1
Have you taken any action to renounce your foreign citizenship?
□ Yes
□ No
Provide explanation:
(Electronic Form Note: Required Field for both Yes and No response.)

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If end date of is not present in question
10.1.0.2, proceed to 10.1.2.0, if present at “Save” return to 10.0.0.0 Summary
Screen

Section 10: Citizenship Information

Section 10.1.2.0 - Country of Citizenship – Not to Present Detailed Entry
Section 10: Dual/Multiple Citizenship & Foreign Passport Information Detail
10.1.2.1
Do you currently hold citizenship with this country?
□ Yes
□ No
Provide explanation:
(Electronic Form Note: Required Field for both Yes and No response.)

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” return to 10.0.0.0 Summary Screen

Section 10: Citizenship Information

Section 10.2.0.0 - Foreign Passport – Initial Screen
Section 10: Foreign Passport (or Identity Card)
10.2.0.1
Have you EVER been issued a passport (or identity card for travel) by a country other
than the U.S.?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “No” At Save/Continue Proceed to Section
11.0.0.0. If “Yes” At Save/Continue Section proceed to 10.2.1.0 Foreign
Passport Information.

Section 10: Citizenship Information

Section 10.2.0.0 - Foreign Passport – Summary
Section 10: Foreign Passport (or Identity Card)
Summary of Foreign Passports you have listed:
#
Country
Actions
1. Mexico

Edit

Delete

2. Syria

Edit

Delete

10.2.0.2
Do you have an additional foreign passport (or identity card) to report?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “No” At Save Proceed to Section 11.0.0.0.
If “Yes” At Save proceed to 10.2.1.0 Foreign Passport Information. Applicant
must answer no to move to section 11.

Section 10: Citizenship Information

Section 10.2.1.0 - Foreign Passport Information
Section 10: Foreign Passport (or Identity Card)
Detail
You responded “Yes” to having been issued a passport (or identity card for
travel) by a country other than the U.S.
10.2.1.1

Provide the country in which the passport (or identity card) was issued.
Country:
10.2.1.2

Provide the date the passport (or identity card) was issued.
Month/Day/Year
Est.
/

/

10.2.1.3

Provide the place the passport (or identity card) was issued.
City
Country

10.2.1.4

Provide the name in which passport (or identity card) was issued:
Last name:
First name:
Middle name:
Suffix:
10.2.1.5

Provide the passport (or identity card) number.

Section 10: Citizenship Information

10.2.1.6

Provide the passport (or identity card) expiration date.
Month/Day/Year
Est.
/

/

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At Save Proceed to Section 10.2.2.0 Foreign
Passports - Travel.

Section 10: Citizenship Information

10.2.2.0 - Foreign Passport Information – Travel (Detailed Entry Branch
from 10.2.1.0)
Section 10: Foreign Passport (or Identity Card)
Travel
10.2.2.1
Have you EVER used this passport (or identity card) for foreign travel?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “No” At Save Proceed to Section 10.2.0.0
Summary. If “Yes” Proceed to Section 10.2.3.0 Foreign Countries Traveled with
Passport.

Section 10: Citizenship Information

Section 10.2.3.0 - Foreign Countries Traveled with Passport
Section 10: Foreign Passport (or Identity Card)
Travel Detail
Provide the countries to which you traveled on this passport (or identity card) and the
dates involved with each.
10.2.3.1
#
Country
From
To
Actions
1.

Italy

/

/

Delete

2.

Italy

/

/

Delete

/

/

3.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At Save Proceed to Section 10.2.0.0
Summary.

Section 10: Citizenship Information

Section 11 SF86 “Where you have lived”
Section 11.0.0.0 – Where you have lived – Initial/Instruction screen
Section 11: Where You Have Lived
List the places where you have lived beginning with your present residence and working back 10
years. Residences for the entire period must be accounted for without breaks. Indicate the actual
physical location of your residence, not a Post Office box or a permanent residence when you
were not physically located there. If you split your time between one or more residences during a
time period, you must list all residences. Do not list residence before your 18th birthday unless to
provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your
permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who
preferably still lives in that area. Do not list people who knew you well for residences completely
outside this 3-year period, and do not list your spouse, cohabitant or other relatives.
Continue

Electronic Form Navigation Note – On continue proceed to Section 11.1.0.0 (first
residential entry). Unless data already exists from a previously completed form in a
system such as e-QIP, proceed to 11.0.0.0 summary.

Section 11: Residence Information

Section 11.0.0.0 – Where you have lived – Summary
Section 11: Where You Have Lived
List the places where you have lived beginning with your present residence and working back 10
years. Residences for the entire period must be accounted for without breaks. Indicate the actual
physical location of your residence, not a Post Office box or a permanent residence when you
were not physically located there. If you split your time between one or more residences during a
time period, you must list all residences. Do not list residence before your 18th birthday unless to
provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your
permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who
preferably still lives in that area. Do not list people who knew you well for residences completely
outside this 3-year period, and do not list your spouse, cohabitant or other relatives.
Summary of where you have lived
#
Time period

Street

City

Actions

1 From 06/2004 To Present 3rd Medical Battalion FPO/AP

Edit

Delete

2 From 01/1998 To 05/2004 Unit 1222 Box 1234

Edit

Delete

11.0.0.1
Do you have an additional residence to report?

APO

□ Yes □ No

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 11.1.0.0, if no proceed to
section 12.0.0.0.

Section 11: Residence Information

Section 11.1.0.0 – Where you have lived – Detail
Section 11: Where You Have Lived (Entry Detail)
Enter residence information.
11.1.0.1
Provide dates of residence.
Date
Month/Year
From:

Jun(06)

To:

Est./Pres.

/
Present

/

11.1.0.2
Is/was this residence:
□ Owned by you
□ Rented or leased by you
□ Military housing
□ Other (Provide explanation)
Explanation:

11.1.0.3
Provide the street address.
Street:
City:
State:

Zip Code:

If outside of the United States provide City and Country.
Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Residence Screen (11.1.2.0) if residence
“to date” is within the past 3 years, otherwise proceed to 11.0.0.0 summary.
If the subject provides an APO/FPO Address, go to Physical Address Screen (11.1.1.0).
If the subject provides address with city and country go to APO/FPO Screen (11.1.3.0).

Section 11: Residence Information

Section 11.1.1.0 – Where you have lived - APO/FPO Provided, Physical Location

Section 11: Where You Have Lived
Physical Location
You have indicated an APO/FPO address; provide physical location data with street address,
base, post, embassy, unit, and country location or home port/fleet headquarter.
11.1.1.1
Provide physical location data:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 11.2.0.0 if residence
“to date” is within the past 3 years, otherwise proceed to 11.0.0.0 summary.

Section 11: Residence Information

Section 11.1.2.0 – Where you have lived - Country Provided, Provide APO/FPO
Section 11: Where You Have Lived
APO/FPO
11.1.2.1
You have indicated an address outside of the United States.
Do/did you have an APO/FPO address while at this location?
□ Yes □ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes proceed to Section 11.1.3.0. If no proceed to
Section 11.2.0.0 if residence “to date” is within the past 3 years, otherwise proceed to
11.0.0.0 summary.

Section 11: Residence Information

Section 11.1.3.0 – Where you have lived - Country Provided, Provide APO/FPO
Section 11: Where You Have Lived
APO/FPO - Detail
You have indicated that you have or had an APO/FPO while at this location.
11.1.3.1
Provide APO/FPO address:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – Proceed to Section 11.2.0.0 if residence “to date” is
within the past 3 years, otherwise proceed to 11.0.0.0 summary.

Section 11: Residence Information

Section 11.2.0.0 – Where you have lived - Person who knew you

Section 11: Where You Have Lived
Person Who Knew You
Provide the name of a neighbor or other person who knows you at this address.
11.2.0.1
Provide the full name.
Name
Last name:
First name:
Middle name:
Suffix:
11.2.0.2
Provide date of last contact.
Date
Month / Year
From:

Est.

/

11.2.0.3
Provide your relationship to this person (check all that apply).
□ Neighbor
□ Friend
□ Landlord
□ Business associate
□ Other (Provide explanation)
Explanation:

11.2.0.4
Provide the following contact information for this person:
Provide evening phone number for this person:
□ I don’t know
(

Check box if International)
Number
Extension

Section 11: Residence Information

11.2.0.5
Provide daytime phone number for this person:
□ I don’t know
(

Check box if International)
Number
Extension

11.2.0.6
Provide cell/mobile phone number for this person:
□ I don’t know
Check box if International)
Number
Extension

(

11.2.0.7
Provide e-mail address for this person:
□ I don’t know

11.2.0.8
Provide street address for this person (including apartment number).
Street:
City:
State:

Zip Code:

If outside of the United States provide City and Country.
Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to (11.0.0.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen (11.2.2.0)
If the subject provides address with city and country go to APO/FPO Screen (11.2.3.0)

Section 11: Residence Information

Section 11.2.2.0 – APO/FPO Provided, Person Who Knew You
Section 11: Where You Have Lived
Person Who Knew You – Physical Location
You have indicated an APO/FPO address, provide physical location data with either street
address, base, post, embassy, unit, and country location or home port/fleet headquarter.
11.2.2.1
Provide physical location data:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” go to Section 11.0.0.0

Section 11: Residence Information

91001

Section 11.2.3.0 - Country Provided, Provide APO/FPO Person Who Knew You
Section 11: Where You Have Lived
Person Who Knew You – APO/FPO Address
11.2.3.0
You have indicated an address outside of the United States. Does the person who knew you have
an APO/FPO address?
□ Yes □ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes proceed to Section 11.2.4.0, if no proceed to
Section 11.0.0.0

Section 11: Residence Information

Section 11.2.4.0 – Country Provided, Provide APO/FPO
Section 11: Where You Have Lived
Person Who Knew You – APO/FPO Address Detail
You have indicated that the person who knew you well has or had an APO/FPO address.
11.2.4.1
Provide APO/FPO address:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At save proceed to Section 11.0.0.0

Section 11: Residence Information

91001

Section 12 SF86 “Where You Went to School”
Section 12.0.0.0 – Where you went to school
Section 12: Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two
years education history.
12.0.0.1
Have you attended any schools in the last 10 years?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes proceed to Section 12.2.0.0, if no
proceed to Section 12.1.0.0

Section 12: Education

Section 12.1.0.0 – Where you went to school
Section 12: Where You Went to School
12.1.0.0
Have you received a degree or diploma more than 10 years ago?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes proceed to Section 12.2.0.0, if no
proceed to Section 13.0.0.0

Section 12: Education

Section 12.0.0.0 – Where you went to school: Summary Screen
Section 12: Where You Went to School
Summary of where you went to school.
# Time Period Name of School
1. 5/2002 – 5/2004

Wilber State

Edit

Delete

Do you have additional education to enter within the last 10 years? Do not list education
before your 18th birthday, unless to provide a minimum of two years education history.
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes is selected proceed to Section 12.2.0.0
If no go to Section 13.0.0.0

Section 12: Education

Section 12.2.0.0 - Where You Went to School Detail
Section 12: Where You Went to School
Detail
12.2.0.1
Provide the dates of attendance.
Date
Month/Year
From:

/

To:

/

Est./Pres.

12.2.0.2
Select the most appropriate code to describe your school.
□ High School
□ College/University/Military College
□ Vocational/Technical/Trade School
□ Correspondence/Distance/Extension/Online School
12.2.0.3
Provide the name of the school:
12.2.0.4
Provide the street address of the school.
For correspondence/distance/extension/online schools, provide the address where the
records are maintained.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
For schools you attended in the last 3 years, list a person who knew you at the school
(instructor, student, etc.). Do not list people for education periods completed more than 3
years ago.
12.2.0.5
Provide the name of person who knows/knew you at school
(for correspondence/distance/extension/online schools, list someone who knew you while
you received this education):
□ I don’t know

Section 12: Education

Section 12: Education

12.2.0.6
Provide current address for this person (including apartment number).
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
12.2.0.7
Provide telephone number for this person.
(

Check box if International)
Number
Extension

Time
Day

12.2.0.8
□ I don’t know
Provide email address for this person:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – Proceed to Section 12.2.1.0

Section 12: Education

Section 12.2.1.0 - Where You Went to School Detail
Section 12: Where You Went to School
Degree/Diploma Received
12.2.1.1
Did you receive a degree/diploma?
□ Yes
□ No
Add Optional Comment

Save

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Electronic Form Navigation Note – If yes proceed to Section 12.2.2.0, if no
proceed to 12.0.0.0 section summary

Section 12: Education

Section 12.2.2.0 - Where You Went to School Detail
Section 12: Where You Went to School
Degrees/Diplomas
12.2.2.1
Identify type of degrees(s)/diploma(s) received and date(s) awarded:
#
Degree/diploma
Other
Month / Year
degree/diploma
1
/
.
2.

Es
t.

/

Electronic Form Navigation Note – Types of degrees for dropdown:
High School Diploma
Associate’s
Bachelor’s
Master’s
Doctorate
Professional Degree (e.g. MD, DVM, JD)
Other
Add Optional Comment

Save

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Electronic Form Navigation Note – Proceed to 12.0.0.0 section summary

Section 12: Education

Actions
Delete

Delete

Section 13a SF86 “Employment Activities – Employment &
Unemployment Record”
Section 13.0.0.0 - Employment Instructions
Section 13: Employment Instructions
List all of your employment activities, including unemployment and self-employment,
beginning with the present and working back 10 years. The entire period must be
accounted for without breaks. If the employment activity was military duty, list separate
employment activity periods to show each change of military duty station.
Do not list employment before your 18th birthday unless to provide a minimum of 2
years employment history.

Continue

Electronic Form Navigation Note – At “Save” proceed to Section 13a.1.0.0

Section 13a: Employment Activities

Section 13a.0.0.0 - Employment Activities - Summary
Section 13a: Employment Activities – Employment & Unemployment Record
Summary
List all of your employment activities, including unemployment and self-employment,
beginning with the present and working back 10 years. The entire period must be
accounted for without breaks. If the employment activity was military duty, list separate
employment activity periods to show each change of military duty station.
Do not list employment before your 18th birthday unless to provide a minimum of 2
years employment history.
Summary of Your Employment Activities:
#
Time period
Type of employment
1

From 01/2000 To
Present

Other Federal
employment

Actions
Edit

Delete

Do you have an additional employment activity to enter?
Yes □
No □
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 13a.1.0.0, if “No”
proceed to Section 13b.0.0.0

Section 13a: Employment Activities

Section 13a.1.0.0 Employment Code and Activity Range
Section 13a: Employment Activities – Employment & Unemployment Record
Detail
13a.1.0.1
Select your employment activity:
□ Active military duty station
□ National Guard/Reserve
□ USPHS Commissioned Corps
□ Other Federal employment
□ State Government (Non-Federal employment)
□ Self-employment
□ Unemployment
□ Federal Contractor
□ Non-government employment (excluding self-employment)
□ Other (Provide explanation)
Explanation

13a.1.0.1
Provide dates of employment.
Date
Month/Year
From:

/

To:

/

Est./Pres.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
Based on the activity code they will be taken to the following screens:
Codes 1, 2, or 3 will proceed to Section 13a.1.1.0.
Codes 4, 5, 8, 9, or 10 will proceed to Section 13a.2.0.0
Code 6 will proceed to Section 13a.3.0.0.
Code 7 will proceed to Section 13a.4.0.0

Section 13a: Employment Activities

Section 13a.1.1.0 Employment Code 1-3
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment
13a.1.1.1
Select the employment status for this position:
□ Full-time
□ Part-time
13a.1.1.2
Provide your assigned duty station during this period.

13a.1.1.3
Provide your most recent rank/position title.

13a.1.1.4
Provide address of duty station.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
13a.1.1.5
Telephone number:
(

Check box if International)
Number
Extension

Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Supervisor Screen. (13a.1.5.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.1.2.0)
Section 13a: Employment Activities

If the subject provides address with city and country go to APO/FPO Screen
(13a.1.3.0)

Section 13a: Employment Activities

Section 13a.1.2.0 Employment Code 1-3 APO/FPO Provided, Physical
Location
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – Physical Location
You have indicated an APO/FPO address; provide physical location data with either
street address, base, post, embassy, unit, and country location or home port/fleet
headquarter.
13a.1.2.1
Provide physical location data:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.1.5.0.

Section 13a: Employment Activities

91001

Section 13a.1.3.0 Employment Code 1-3 Physical Location Country
Provided, Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – APO/FPO
13a.1.3.1
You have indicated an address outside of the United States. Do you or did you have an
APO/FPO address while at this location?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If yes, proceed to section 13a.1.4.0, else
proceed to 13a.1.5.0

Section 13a: Employment Activities

Section 13a.1.4.0 Employment Code 1-3 Physical Location Country
Provided, Provide APO/FPO Detail
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – APO/FPO Detail
13a.1.4.1
Provide APO/FPO address:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 13a.1.5.0

Section 13a: Employment Activities

91001

Section 13a.1.5.0 Supervisor Screen for Military entries
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – Supervisor
13a.1.5.1
Provide the name of your supervisor.

13a.1.5.2
Provide the rank/position title of your supervisor.

13a.1.5.3
Provide the email address of your supervisor.
□ I don’t know

13a.1.5.4
Provide the physical work location of your supervisor.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
13a.1.5.5 Provide supervisor telephone number:
(

Check box if International)
Number
Extension

Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Additional Entries. (13a.5.0.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.1.6.0)

Section 13a: Employment Activities

If the subject provides address with city and country go to APO/FPO Screen
(13a.1.7.0)

Section 13a: Employment Activities

Section 13a.1.6.0 Employment Code 1-3 APO/FPO Provided, Physical
Location
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – Supervisor Physical Location
You have indicated an APO/FPO address for your supervisor; provide physical location
data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
13a.1.6.1
Provide physical location data of your supervisor:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 13a.5.0.0

Section 13a: Employment Activities

91001

Section 13a.1.7.0 Employment Code 1-3 Supervisor Physical Location
Country Provided, APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – Supervisor APO/FPO
13a.1.7.1
You have indicated an address outside of the United States. Did/does your supervisor
have an APO/FPO address while at this location?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to section 13a.1.8.0, if “No”
proceed to section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.1.8.0 Employment Code 1-3 Supervisor Physical Location
Country Provided, APO/FPO Detail
Section 13a: Employment Activities – Employment & Unemployment Record
Military Employment – Supervisor APO/FPO Detail
13a.1.8.1
Provide APO/FPO address:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 13A.5.0.0

Section 13a: Employment Activities

91001

Section 13a.2.0.0 Non-Military Employment - Codes 4, 5, 8, 9, 10
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment
13a.2.0.1
Provide most recent position title.

13a.2.0.2
Select the employment status for this position:
□ Full-time
□ Part-time
13a.2.0.3
Provide the name of your employer.

13a.2.0.4
Provide the address of employer.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:

13a.2.0.5
Provide telephone number
(

Check box if International)
Number
Extension

Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 13a.2.1.0

Section 13a: Employment Activities

Section 13a.2.1.0 Non-Military Employment - Codes 4, 5, 8, 9, 10 – Physical
Location
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Physical Location
13a.2.1.1
Is/was your physical work address different than your employer’s address?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 13a.2.2.0, if “No”
proceed to Section 13a.2.6.0

Section 13a: Employment Activities

Section 13a.2.2.0 Non-Military Employment - Codes 4, 5, 8, 9, 10 – Physical
Location
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Physical Location Detail
13a.2.2.1
Provide the work address where you are/were physically located.
Street:
City:
State:

Zip Code:

If outside of the United States provide City and Country.
Country:
13a.2.3.2
Provide telephone number:
(

Check box if International)
Number
Extension

Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Supervisor Screen. (13a.2.6.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.2.3.0)
If the subject provides address with city and country go to APO/FPO Screen
(13a.2.4.0)

Section 13a: Employment Activities

Section 13a.2.3.0 Non-Military APO/FPO Provided, Physical Location
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Physical Location
You have indicated an APO/FPO address; provide physical location data with either
street address, base, post, embassy, unit, and country location or home port/fleet
headquarter.
13a.2.3.1
Provide physical location data:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 13a.2.6.0

Section 13a: Employment Activities

91001

Section 13a.2.4.0 Non-Military - Physical Location Country Provided,
Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – APO/FPO
13a.2.4.1
You have indicated an address outside of the United States. Do you or did you have an
APO/FPO address while at this location?
□Yes
□No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 13a.2.5.0, if “No”
proceed to 13a.2.6.0

Section 13a: Employment Activities

Section 13a.2.5.0 Non-Military - Physical Location Country Provided,
Provide APO/FPO Detail
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – APO/FPO Detail
13a.2.5.1
Provide APO/FPO address:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.2.6.0

Section 13a: Employment Activities

Section 13a.2.6.0 Non-Military – Supervisor
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Supervisor
13a.2.6.1
Provide the name of your supervisor.

13a.2.6.2
Provide the position title of your supervisor.

13a.2.6.3
Provide the email address of your supervisor.
□ I don’t know

13a.2.6.4
Provide the physical work location of your supervisor.
Street:
City:
State:

Zip Code:

If outside of the United States provide City and Country.
Country:
13a.2.6.0
Provide the telephone number for this supervisor:
(

Check box if International)
Number
Extension

Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Add Entry Screen (13a.5.0.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.2.7.0)
Section 13a: Employment Activities

If the subject provides address with city and country go to APO/FPO Screen
(13a.2.8.0)

Section 13a: Employment Activities

Section 13a.2.7.0 - Non-Military Supervisor APO/FPO Provided
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Supervisor Physical Address
You have indicated an APO/FPO address for your supervisor; provide physical location
data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
13a.2.7.1
Provide physical location data of your supervisor:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.2.8.0 Non-Military - Supervisor Location Country Provided,
Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Supervisor APO/FPO
13a.2.8.1
You have indicated an address outside of the United States. Did/does your supervisor
have an APO/FPO address while at this location?
□Yes
□No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to 13a.2.9.0, if “No” proceed
to 13a.5.0.0

Section 13a: Employment Activities

Section 13a.2.9.0 Non-Military - Supervisor Location Country Provided,
Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Non-Military Employment – Supervisor APO/FPO
13a.2.9.1
Provide APO/FPO address of your supervisor:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.3.0.0 Self Employment
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment
13a.3.0.1
Provide most recent position title:

13a.3.0.2
Select the employment status for this position:
□ Full-time
□ Part-time
13a.3.0.3
Provide the name of your employment.

13a.3.0.4
Provide address of this employment:
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country
:
13a.3.0.5
Provide telephone number:
(

Check box if International)
Number
Extension

Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.3.1.0

Section 13a: Employment Activities

Section 13a.3.1.0 Self Employment
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Physical Address
13a.3.1.1
Is your physical work address different than your employment address?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to 13a.3.2.0, if “No” proceed
to 13a.3.6.0

Section 13a: Employment Activities

Section 13a.3.2.0 Self Employment Physical Location
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Physical Address Detail
13a.3.2.1
Provide the work address where you are/were physically located.
Street:
City:
State:

Zip Code:

If outside of the United States provide City and Country.
Country:
13a.3.2.2
Provide the telephone number for this address:
(_ Check box if International)
Number
Extension
Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Verifier Screen. (13a.3.6.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.3.3.0)
If the subject provides address with city and country go to APO/FPO Screen
(13a.3.4.0)

Section 13a: Employment Activities

Section 13a.3.3.0 Self Employment APO/FPO Provided, Physical Location
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Physical Address Detail
You have indicated an APO/FPO address; provide physical location data with either
street address, base, post, embassy, unit, and country location or home port/fleet
headquarter.
13a.3.3.1
Provide physical location data:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.3.6.0

Section 13a: Employment Activities

Section 13a.3.4.0 Self Employment - Physical Location Country Provided,
Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – APO/FPO
13a.3.4.1
You have indicated an address outside of the United States. Do you or did you have an
APO/FPO address while at this location?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 13a.3.5.0, if “No”
proceed to Section 13a.3.6.0

Section 13a: Employment Activities

Section 13a.3.5.0 Self Employment - Physical Location Country Provided,
Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – APO/FPO Detail
13a.3.5.1
Provide APO/FPO address:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.3.6.0

Section 13a: Employment Activities

Section 13a.3.6.0 Self Employment Verifier
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Verifier
13a.3.6.1
Provide the name of someone that can verify your self-employment.
Last name:
First name:
13a.3.6.2
Provide the address of this verifier:
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
13a.3.6.3
Provide the telephone number for this person:
(_ Check box if International)
Number
Extension
Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to Fired, Quit after told you would be
fired, allegations of misconduct, unsatisfactory performance, written warning
screen. (13a.5.0.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.3.7.0)
If the subject provides address with city and country go to APO/FPO Screen
(13a.3.8.0)

Section 13a: Employment Activities

Section 13a.3.7.0 Self Employment-Verifier APO/FPO Provided, Physical
Location
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Verifier Physical Address
You have indicated an APO/FPO address for your self employment verifier; provide
physical location data with either street address, base, post, embassy, unit, and country
location or home port/fleet headquarter.
13a.3.7.1
Provide physical location data of this person:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.3.8.0 Self Employment-Verifier - Physical Location Country
Provided, Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Verifier APO/FPO
13a.3.8.1
You have indicated an address outside of the United States. Does your self employment
verifier have an APO/FPO address?
□Yes
□No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 13a.3.9.0, if “No”
proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.3.9.0 Self Employment-Verifier - Physical Location Country
Provided, Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Self Employment – Verifier APO/FPO Detail
13a.3.9.1
Provide APO/FPO address of this person:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.4.0.0 - Unemployment
Section 13a: Employment Activities – Employment & Unemployment Record
Unemployment
13a.4.0.1
Provide the name of someone who can verify your unemployment activities and means of
support.
Last name:
First name:
Provide the address of this verifier:
13a.4.0.2
Street:
City:
State:

Zip Code:

If outside of the United States provide City and Country.
Country:
13a.4.0.3
Provide the telephone number for this person:
(_ Check box if International)
Number
Extension
Time
Day

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If the subject provides a U.S. address, go to (13a.5.0.0)
If the subject provides an APO/FPO Address, go to Physical Address Screen
(13a.4.1.0)
If the subject provides address with city and country go to APO/FPO Screen
(13a.4.2.0)

Section 13a: Employment Activities

Section 13a.4.1.0 - Unemployment Verifier APO/FPO Provided, Physical
Location
Section 13a: Employment Activities – Employment & Unemployment Record
Unemployment – Verifier Physical Address
You have indicated an APO/FPO address for your unemployment verifier; provide
physical location data with either street address, base, post, embassy, unit, and country
location or home port/fleet headquarter.
13a.4.1.1
Provide physical location data of this person:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.4.2.0 Unemployment-Verifier Physical Location Country
Provided, Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Unemployment – Verifier APO/FPO
13a.4.2.1
You have indicated an address outside of the United States. Does your unemployment
verifier have an APO/FPO address?
□Yes
□No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 13a.4.3.0, if “No”
proceed to Section 13a.5.0.0

Section 13a: Employment Activities

Section 13a.4.3.0 Unemployment-Verifier Physical Location Country
Provided, Provide APO/FPO
Section 13a: Employment Activities – Employment & Unemployment Record
Unemployment – Verifier APO/FPO Detail
13a.4.3.1
Provide APO/FPO address of this person:
Address:

3rd Medical Battalian, 3rd FSSG

APO or FPO:
APO/FPO State Code:

APO/FPO Pacif ic (AP)

Zip Code:

91001

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Summary

Section 13a: Employment Activities

Section 13a.5.0.0 Fired, Quit after told you would be fired, allegations of
misconduct, unsatisfactory performance, written warning.
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving
13a.5.0.1
Provide the reason for leaving the employment activity.

Add Optional Comment

Save

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Conditional based on date(s) selected, if employment record is to present,
section is to be bypassed. At “Save” proceed to Section 13a.5.1.0.

Section 13a: Employment Activities

Section 13a.5.1.0 Fired, Quit after told you would be fired, allegations of
misconduct, unsatisfactory performance, written warning.
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving
Electronic Form Navigation Note – Question only presented if “To” date for
employment is in the last seven years.
13a.5.1.1
For this employment have any of the following happened to you in the last seven (7)
years?
• Fired
• Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
• Left by mutual agreement following notice of unsatisfactory performance
□ Yes
□ No
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proceed to Section 13a.6.0.0

Section 13a: Employment Activities

Section 13a.5.1.0 Fired, Quit after told you would be fired, allegations of
misconduct, unsatisfactory performance, written warning. Summary
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving
Summary of reasons for leaving
Date of Incident
Type of Incident

Actions

1 02/03/2001

Fired

Edit

Delete

2 11/21/2007

Left by mutual agreement after allegations

Edit

Delete

13a.5.0.1
In the last seven (7) years do you have another reason for leaving to report for this
employment?
□ Yes
□ No
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proceed to Section 13a.6.0.0

Section 13a: Employment Activities

Section 13a.5.2.0 Fired, Quit after told you would be fired, allegations of
misconduct, unsatisfactory performance, written warning.
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving
Beginning with the most recent occurrence, provide date fired, quit, or left, and other
information requested.
13a.5.2.1
Select the type of incident:

Electronic Form Navigation Note – Dropdown contains:
• Fired
• Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
• Left by mutual agreement following notice of unsatisfactory performance
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• Fired
o Proceed to Section 13a.5.3.0
• Quit after being told you would be fired
o Proceed to Section 13a.5.4.0
• Left by mutual agreement following charges or allegations of misconduct
o Proceed to Section 13a.5.5.0
• Left by mutual agreement following notice of unsatisfactory performance
o Proceed to Section 13a.5.6.0

Section 13a: Employment Activities

Section 13a.5.3.0 – Fired
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving - Fired
13a.5.3.1
Provide the reason for being fired.

13a.5.3.2
Provide the date you were fired.
Month/Year
Est.
□
/
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Summary

Section 13a: Employment Activities

Section 13a.5.4.0 - Quit after being told you would be fired
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving – Quit after Being Told You Would be Fired
13a.5.4.1
Provide the reason for quitting.

13a.5.4.2
Provide the date you quit after being told you would be fired.
Month/Year
Est.
/

□

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Summary

Section 13a: Employment Activities

Section 13a.5.5.0 – Quit Following Charges or Allegations of Misconduct
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving - Left by mutual agreement following charges or allegations of
misconduct
13a.5.5.1
Provide the charges or allegations of misconduct.

13a.5.5.2
Provide the date you left following charges or allegations of misconduct.
Month/Year
Est.
/

□

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Section 13a: Employment Activities

Section 13a.5.6.0 – Left after notice of Unsatisfactory Performance
Section 13a: Employment Activities – Employment & Unemployment Record
Reason for Leaving - Left by mutual agreement following notice of unsatisfactory
performance
13a.5.6.1
Provide the reason(s) for unsatisfactory performance.

13a.5.6.2
Provide the date you left by mutual agreement following a notice of unsatisfactory
performance.
Month/Year
Est.
/

□

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Summary

Section 13a: Employment Activities

Section 13a.6.0.0 – Received Discipline or Warning
Section 13a: Employment Activities – Employment & Unemployment Record
Received Discipline or Warning
Electronic Form Navigation Note – Question only presented if “To” date for
employment is in the last seven years.
13a.6.0.1
For this employment, in the last seven (7) years have you received a written warning,
been officially reprimanded, suspended, or disciplined for misconduct in the workplace,
such as a violation of security policy?
□ Yes
□ No
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proceed to Section 13a.0.0.0, Summary

Section 13a: Employment Activities

Section 13a.6.0.0 – Received Discipline or Warning Summary
Section 13a: Employment Activities – Employment & Unemployment Record
Received Discipline or Warning
Summary of discipline and warnings
Date of Incident
Type of Discipline/Warning

Actions

1 02/03/2001

Written up for extended breaks

Edit

Delete

2 11/21/2007

Warned for leaving computer logged on

Edit

Delete

Do you have another instance of discipline or a warning to provide?
□ Yes
□ No
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Section 13a: Employment Activities

Section 13a.6.1.0 – Received Discipline or Warning
Section 13a: Employment Activities – Employment & Unemployment Record
Received Discipline or Warning Detail
13a.6.1.1
Provide the month and year you were warned, reprimanded, suspended or disciplined.
Month/Year
Est.
/

□

13a.6.1.2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

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Summary

Section 13a: Employment Activities

Section 13b SF86 “Employment Activities – Former Federal Service”
Section 13b.0.0.0 Former Federal Civilian Employment
Section 13b: Former Federal Service, Excluding Military Service, Not Indicated
Previously
Do you have former federal civilian employment, excluding military service, NOT
indicated previously, to report?
□ Yes
□ No
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13b Employment Activities

Section 13b.0.0.0 Former Federal Civilian Employment - SUMMARY
Section 13b: Former Federal Service, Excluding Military Service, Not Indicated
Previously
# Dates of Federal Service Agency Position title
1 From 01/1992 To 02/1994 OPM

Analyst

Actions
Edit

Delete

13b.0.0.1
Do you have additional former federal civilian employment, excluding military service,
NOT indicated previously, to report?
□ Yes
□ No
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to Section 13c.0.0.0

13b Employment Activities

Section 13b.1.0.0 Former Federal Civilian Employment - Detail
Section 13b: Former Federal Service, Excluding Military Service, Not Indicated
Previously Detail
13b.1.0.1
Provide dates of federal civilian employment.
Date
Month/Year
Est./Pres.
From:

/

To:

/

13b.1.0.2
Provide the name of the federal agency for which you are/were employed.

Electronic Form Navigation Note – Drop down to contain list of Federal
Government agencies.
13b.1.0.3
Provide your position title.

13b.1.0.4
Provide the location of the agency.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
Add Optional Comment

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summary

13b Employment Activities

Section 13c SF86 “Employment Record”
Section 13c.0.0.0 Employment Record
Section 13c: Employment Record
Have any of the following happened to you in the last seven (7) years at employment
activities that you have not previously listed? (If Yes, you will be required to add an
additional employment in Section 13a)






Fired from a job?
Quit a job after being told you would be fired?
Have you left a job by mutual agreement following charges or allegations of
misconduct?
Left a job by mutual agreement following notice of unsatisfactory performance?
Received a written warning, been officially reprimanded, suspended, or
disciplined for misconduct in the workplace, such as violation of a security
policy?

13c.0.0.1
□ Yes □ No
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proceed to section 14.0.0.0.

Section 13c: Employment Record

Section 14 SF86 “Selective Service Record”
Section 14.0.0.0 – Selective Service Record
Section 14: Selective Service Record
14.0.0.1
Were you born a male after December 31, 1959?
□ Yes
□ No
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proceed to Section 15.0.0.0.

Section 14: Selective Service Record

Section 14.1.0.0 – Selective Service Record Detail
Section 14: Selective Service Record
Detail
14.1.0.1
Have you registered with the Selective Service System (SSS)?
□ Yes
Provide registration number. (The Selective Service website, www.sss.gov, can
help provide the registration number for persons who have registered). Note:
Selective Service Number is not your Social Security Number.
□ No
Provide explanation.
□ I don’t know
Provide explanation.

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Section 14: Selective Service Record

Section 15 SF86 “Military History”
Section 15.1.0.0 – Military History - (Initial Question, no Entries provided)
Section 15: Military History
15.1.0.1
Have you EVER served in the U.S. Military?
□ Yes
□ No
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proceed to 15.3.0.0.

Sections 15: Military History

Section 15.1.0.0 – Military History Summary Page – (Upon Completion of an
Entry)
Section 15: Military History

#

Time period

Branch

Status

Actions

1 From 06/2004 To Present Army

Inactive Reserve

Edit

Delete

2 From 01/1998 To 05/2004 Army

Active Duty

Edit

Delete

15.1.0.1
Do you have additional military service to report?

□ Yes □ No

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proceed to 15.2.0.0.

Sections 15: Military History

Section 15.1.1.0 – Military History Detail
Section 15: Military History
Detail
You responded ‘Yes’ to having served in the U.S. Military:
15.1.1.1
Provide the branch of service you served in:

Electronic Form Navigation Note – Dropdown above to include:
□Army
□Army National Guard
□Navy
□Air Force
□Air National Guard
□Marine Corps
□Coast Guard
15.1.1.3
Provide your status.

Electronic Form Navigation Note – Dropdown above to include:
□Active Duty
□Active Reserve
□Inactive Reserve
15.1.1.3
Officer or enlisted:
Not Applicable
Officer
Enlisted
15.1.1.4
Provide your service number.

Sections 15: Military History

15.1.1.5
Provide your dates of service.
Date
Month/Year
From:

/

To:

/

Est./Pres.

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History Discharged

Sections 15: Military History

Section 15.1.2.0 – Military History: Discharged
Section 15: Military History
Discharge
15.1.2.1
Were you discharged from this instance of U.S. military service, to include Reserves, or
National Guard?
□ Yes
□ No
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proceed to Section 15.0.0.0.

Sections 15: Military History

Section 15.1.3.0 – Military History: Discharged Detail
Section 15: Military History
Discharge Detail
You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves,
or National Guard; answer the following:
15.1.3.1
Provide the type of discharge you received:
□ Honorable
□ Dishonorable
□ Under Other than Honorable Conditions
□ General
□ Bad Conduct
□ Other (provide type)
Provide other discharge type:

15.1.3.2
Provide the date of discharge listed above.
Month/Year
Est.
/
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“Honorable,” proceed to section 15.1.4.0, if “Honorable” proceed to section
15.0.0.0 summary.

Sections 15: Military History

Section 15.1.4.0 – Military History: Discharged Detail
Section 15: Military History
Discharge Detail (all discharge types except “Honorable”)
15.1.4.1
Provide the reason(s) for the discharge.

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Sections 15: Military History

Section 15.2.0.0 – Military History: Discipline
Section 15: Military History
Discipline
15.2.0.1
In the last 7 years, have you been subject to court martial or other disciplinary procedure
under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast,
Article 135 Court of Inquiry, etc?
□ Yes
□ No
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Section 15.2.1.0. If they check “No” they will proceed to 15.3.0.0.

Sections 15: Military History

Section 15.2.0.0 – Military History: Discipline Summary
Section 15: Military History
Discipline Summary
Summary of Military Discipline
# Date of Action
Offense

Actions

1

06/2004

Captain’s Mast

Edit

Delete

2

01/1998

Article 15

Edit

Delete

15.2.0.1
In the last 7 years do you have an additional instance of military discipline to report?
□ Yes □ No
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Sections 15: Military History

Section 15.2.1.0 – Military History: Discipline Detail
Section 15: Military History
Discipline Detail
You responded ‘Yes’ to having been subject to court martial or other disciplinary
procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15,
Captain’s mast, Article 135 Court of Inquiry, etc in the last 7 years.
15.2.1.1
Provide the date of the court martial or other disciplinary procedure.
Month/Year
Est.
/
15.2.1.2
Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for
which you were charged.

15.2.1.3
Provide the name of the disciplinary procedure, such as Court Martial, Article 15,
Captain’s mast, Article 135 Court of Inquiry, etc.

15.2.1.4
Provide the description of the military court or other authority in which you were charged
(title of court or convening authority, address, to include city and state or country if
overseas).

15.2.1.5
Provide the description of the final outcome of the disciplinary procedure, such as found
guilty, found not guilty, fine, reduction in rank, imprisonment, etc.

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15.2.0.0

Sections 15: Military History

Section 15.3.0.0 – Foreign Military Service
Section 15: Military History
Foreign Service
Have you EVER served, as a civilian or military member in a foreign country’s military,
intelligence, diplomatic, security forces, militia, other defense force, or government
agency?
□ Yes
□ No
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16.0.0.0.

Sections 15: Military History

Section 15.3.0.0 – Foreign Military Service Summary
Section 15: Military History
Foreign Military Service Summary
Summary of foreign military service
#
Time period
Branch Country

Actions

1 From 06/2004 To Present Army

Iraq

Edit

Delete

2 From 01/1998 To 05/2004 Army

N. Korea

Edit

Delete

15.3.0.0
Do you have an additional foreign military service to report?

□ Yes □ No

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Sections 15: Military History

Section 15.3.1.0 – Foreign Military Service Detail
Section 15: Military History
Foreign Military Service Detail
You responded ‘Yes’ to having EVER served as a civilian or military member in a
foreign country’s military, intelligence, diplomatic, security forces, militia, other defense
force, or government agency.
15.3.1.1
During your foreign service, which organization were you serving under:
Electronic Form Navigation Note – Applicant may select only one.
□Military (Specify Army, Navy, Air Force, Marines, etc), Specify
□Intelligence Service
□Diplomatic Service
□Security Forces
□Militia
□Other Defense Forces, Specify
□Other Government Agency, Specify
15.3.1.2
Provide the name of the foreign organization.

15.3.1.3
Provide your period of service.
Date
Month/Year
From:

/

To:

/

Est./Pres.

15.3.1.4
Provide the name of the country.

15.3.1.5
Provide your highest position/rank held.

15.3.1.6
Provide the division/department/office in which you served.

Sections 15: Military History

15.3.1.7
Provide a description of the circumstances of your association with this organization.

15.3.1.8
Provide a description of the reason for leaving this service.

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Sections 15: Military History

Section 15.3.2.0 – Foreign Military Service Contact
Section 15: Military History
Foreign Military Service Contact
15.3.2.1
Do you maintain contact with current or former associates, colleagues, or acquaintances
from your service in this organization?
□ Yes
□ No
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Sections 15: Military History

Section 15.3.2.0 – Foreign Military Service Contact Summary
Section 15: Military History
Foreign Military Service Contact Summary
Summary of foreign military service contacts
#
Time period
Name
Country
1 From 06/2004 To Present Lin Deshi

China

2 From 01/1998 To 05/2004 Hans Melchior Germany

Actions
Edit

Delete

Edit

Delete

15.3.2.1
Do you have an additional foreign military service contacts to report?
□ Yes
□ No
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Sections 15: Military History

Section 15.3.3.0 – Foreign Military Service Contact Detail
Section 15: Military History
Foreign Military Service Contact Detail
You responded ‘Yes’ to maintaining contact with current or former associates,
colleagues, acquaintances from your service in this organization; provide full name,
address (if known), official title, length of association, and frequency of contact for each
former associate, colleague or acquaintance with whom you maintain contact.
15.3.3.1
Provide the contact’s full name.
Last name:
First name:
Middle name:
Suffix:
15.3.3.2
Provide the contact’s address.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
15.3.3.3
Provide the contact’s official title.

15.3.3.4
Provide the length of your association with the contact.
Date
Month/Year
Est./Pres.
From:

/

To:

/

15.3.3.5
Provide the frequency of contact.

Sections 15: Military History

Add Optional Comment

Save

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Section 15.3.2.0.

Sections 15: Military History

Section 16 SF86 “People Who Know You Well”
Section 16.0.0.0 - People who know you well
Section 16: People Who Know You Well
Provide 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 your workplace, school, or neighborhood, and whose
combined association with you covers at least the last seven (7) years. Do not list your
spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.
Continue

Save

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to Section 16.1.0.0.

Section 16: People Who Know You Well

Section 16.0.0.0 People who know you well, summary
Section 16: People Who Know You Well
Provide 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 your workplace, school, or neighborhood and whose
combined association with you covers at least the last seven (7) years. Do not list your
spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.
Summary of People Who Know You Well
#
Dates known
Reference name

Actions

1 From 06/2000 To Present Doe, John

Edit

Delete

2 From 03/1980 To Present Doe, Jane

Edit

Delete

16.0.0.1
Do you have an additional person who knows you well to list?
□ Yes
□ No
Add Optional Comment

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and they have entered at least 3 people proceed to Section 17.0.0.0.

Section 16: People Who Know You Well

Section 16.1.0.0 - People who know you well detail.
Section 16: People Who Know You Well
Detail
16.1.0.1
Provide dates known.
Date
Month/Year
From:

/

To:

/

Est./Pres.

16.1.0.2
Provide full name.
Last Name:
First Name:
Middle Name:
Suffix:
16.1.0.3
Provide rank/title
□ Not applicable

16.1.0.4
Provide relationship to you: (Check all that apply)
□ Neighbor
□ Friend
□ Work associate
□ Schoolmate
□ Other (Provide explanation)
Explanation:

16.1.0.5
Provide phone number for this person.
□ I don’t know
(

Check box if International)
Number
Extension

Time
Evening

Section 16: People Who Know You Well

16.1.0.6
Provide mobile/cell phone number for this person.
□ I don’t know
Check box if International)
Number
Extension

(

Time
Evening

16.1.0.7
Provide e-mail address for this person.
□ I don’t know

16.1.0.8
Provide home or work address for this person.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
Add Optional Comment

Save

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Summary

Section 16: People Who Know You Well

Section 17 SF86 “Marital Status”
Section 17.0.0.0 – Marital Status
Section 17: Marital Status
17.0.0.1
Provide your current marital status:

Electronic Form Navigation Note – Dropdown contains:
□ Never married
□ Married (including Common Law)
□ Separated
□ Annulled
□ Divorced
□ Widowed
Add Optional Comment

Save

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Electronic Form Navigation Note – Applicant will select one of the above statuses
from the drop-down and click “Save”
• If applicant selects “Never married” they will proceed to Section 17.3.0.0,
Cohabitant.
• If applicant selects “Married” or “Separated”, they will proceed to Section
17.1.0.0 Current Spouse Detail.
• If the applicant selects “Widowed”, “Divorced”, or “Annulled” they will
proceed to Section 17.2.1.0, Widowed, Divorced, or Annulled Detail.

Section 17: Marital Status

Section 17a.1.0.0 – Current Spouse
Section 17: Marital Status
Current Spouse
You selected “Married” or “Separated.”
17.1.0.1
Complete the following about your current spouse only.
Provide spouse’s full name.
Last Name:
First Name:
Middle Name:
Suffix:
17.1.0.2
Provide spouse’s date of birth.
Month/Day/Year
/

Est.

/

17.1.0.3
Provide spouse’s place of birth.
City:
County:
State:
Country:

Add Optional Comment

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foreign birth proceed to section 17.1.1.0, if not proceed to section 17.1.3.0

Section 17: Marital Status

Section 17.1.1.0 – Foreign born spouse detail
Section 17: Marital Status
Foreign Born Spouse Detail
17.1.1.1
For your foreign born spouse, provide one type of documentation that he or she possesses
and the document number.
□ FS 240 or 545
□ DS 1350
□ U.S. Citizenship certificate
□ U.S. Passport (current or most recent)
□ Alien registration
□ U.S. Naturalization certificate
□ None (Provide explanation)
□ Other (Provide explanation)
Explanation:

17.1.1.2
Provide document number.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 17.1.3.0

Section 17: Marital Status

Section 17a.1.3.0 – Spouse detail continued
Section 17: Marital Status
Spouse Detail Continued
Provide your spouse’s U.S. Social Security Number.
17.1.3.1
Not Applicable
-

#

-

17.1.3.2
Provide other names used by your spouse (such as maiden names, names by other
marriages, nicknames, etc. and provide dates used for each name).
□ Not applicable
Name
Maiden
Dates used
Name
Last Name:

1.

Maiden
name?

First Name:
Middle
Name:

Date
From:

/

To:

/

Suffix:
17.1.3.3
Provide your spouse’s country(ies) of citizenship.
#
Country
1.
17.1.3.4
Provide date married.
Month/Day/Year
/

Month/Year

Est.

/

Section 17: Marital Status

Est./Pres.

17.1.3.5
Provide place married.
City:
County:
(Provide Country, if outside the United States; otherwise, provide State).
State:
Country:
17.1.3.6
Provide your spouse’s current address, if different than your current address.
□ Use my current address.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
17.1.3.7
Provide telephone number.
□ Use my current telephone number
(

Check box if International)
Number
Extension

Time
Day

17.1.3.8
Provide email address.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If 17.1.3.6 “Use my current address” is not
checked and a foreign country is provided at “Save” proceed to section 17.1.4.0,
if an APO/FPO address is provided proceed to section 17.1.5.0, else proceed to
section 17.1.6.0

Section 17: Marital Status

Section 17.1.4.0 – Spouse APO/FPO
Section 17: Marital Status
Spouse
17.1.4.1
Does your spouse have an APO/FPO address?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to section 17.1.4.2, if “No”
proceed to 17.1.6.0

Section 17: Marital Status

Section 17.1.4.2 – Spouse APO/FPO Detail
Section 17: Marital Status
Spouse APO/FPO Detail
17.1.4.2
Provide your spouse’s APO/FPO address.
StreetAddress/Unit/Duty
Location:
City or Post Name:
Provide State for ports in the United States; or Country location.
State:

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 17.1.6.0

Section 17: Marital Status

Section 17.1.5.0 – Spouse APO/FPO Detail
Section 17: Marital Status
Spouse Physical Location Detail
You have indicated an APO/FPO address for your spouse; provide physical location data
with street address, base, post, embassy, unit, and country location or home port/fleet
headquarter.
17.1.5.1
Provide physical location data for your spouse:
Street Address/Unit/ 3rd Medical Battalian, 3rd FSSG
Duty Location:
City or Post Name:
Provide State for ports in United States, or Country location.
State:

APO/FPO Pacif ic (AP)

Zip Code:

91001

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 17.1.6.0

Section 17: Marital Status

Section 17.1.6.0 – Spouse Separation
Section 17: Marital Status
Separation Status
Are you separated from your spouse?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 17.1.7.0, if “No”
proceed to 17.0.0.0

Section 17: Marital Status

Section 17.1.7.0 – Spouse Detail
Section 17: Marital Status
Separation Detail
17.1.7.1
Provide date of separation.
Month/Day/Year
/

Est.

/

17.1.7.2
If legally separated, provide the location of the record.
□ Not Applicable
City:
(Provide Country, if outside the United States; otherwise, provide State and Zip Code.)
State:

Zip Code:

Country:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to screen 17.2.0.0.

Section 17: Marital Status

Section 17.2.0.0 – Former Spouse
Section 17: Marital Status
Former Spouse
Do you have a former spouse (such as divorced, annulled, widowed, or other former
spouses) to report?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” at “Save” proceed to section 17.2.1.0,
if no proceed to section 17.3.0.0.

Section 17: Marital Status

Section 17.2.0.0 – Former Spouse Summary
Section 17: Marital Status
Former Spouse Summary
17.2.0.1
Former spouse(s)
#
Full name

Date married

1 Matthews, Jenny P(IO) 03/02/1980

Actions
Edit

Delete

17.2.0.2
Do you have any additional former spouse (such as divorced, annulled, widowed, or other
former spouses) to report?
□ Yes □ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to section 17.2.1.0, if “No”
proceed to section 17.3.0.0

Section 17: Marital Status

Section 17.2.1.0 – Former Spouse Detail
Section 17: Marital Status
Former Spouse Detail
Provide information about your former spouse (such as divorced, annulled, widowed, or
other former spouses).
17.2.1.1
Provide the full name of your former spouse.
Name
Last Name:
First Name:
Middle Name:
Suffix:
17.2.1.2
Provide the date of birth of your former spouse.
Month/Day/Year
Est.
/

/

17.2.1.3
Provide the place of birth for your former spouse.
City:
State:
Country:
17.2.1.4
Provide the country(ies) of citizenship for your former spouse.
#
Country
1.

Section 17: Marital Status

17.2.1.5
Provide the date you married your former spouse.
Month/Day/Year
Est.
/

/

17.2.1.6
Provide the place married.
City:
(Provide Country, if outside the United States; otherwise, provide State)
State:
Country:
17.2.1.7
Provide the status of this marriage.
Divorced
Widowed
Annulled
17.2.1.8
Provide the date divorced, annulled or widowed.
Month/Day/Year
Est.
/

/

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – After “Save” if “Divorced” or “Annulled”
proceed to Section 17.2.2.0, Divorced/Annulled Detail, if “Widowed” or deceased
proceed to section 17.2.0.0. Summary

Section 17: Marital Status

Section 17.2.2.0 – Divorced/Annulled Detail
Section 17: Marital Status
Divorced or Annulled Detail
17.2.2.1
For your divorced or annulled marriage, provide where the record is located.
City:
(Provide Country, if outside the United States; otherwise, provide State and Zip Code.)
State:

Zip Code:

Country:
17.2.2.3
Is this former spouse deceased?
□ Yes
□ No
□ I don’t know
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” if former spouse not deceased or
the subject does not know, proceed to Section 17.2.3.0, Divorced/Annulled
Detail, if former spouse is deceased proceed to section 17.2.0.0. Summary

Section 17: Marital Status

Section 17.2.3.0 – Divorced/Annulled Detail
Section 17: Marital Status
Divorced or Annulled Detail
17.2.3.1
For divorced or annulled marriage provide last known address of the former spouse.
□ I don’t know
Street:
City:
(Provide Country, if outside the United States; otherwise, provide State and Zip Code.)
State:

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 17.2.0.0 Former Spouse
Summary.

Section 17: Marital Status

Section 17.3.0.0 – Cohabitant(s)
Section 17: Marital Status
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 with for reasons of convenience
(e.g. a roommate). If applicable, complete the following about your cohabitant. If your
cohabitant was born outside the U.S., provide citizenship information.
17.3.0.1
Do you presently reside with a cohabitant?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – f the applicant answers “Yes”, they will go to
Section 17.3.1.0, Cohabitant Detail. If they check “No” they will proceed to
Section 18.0.0.0.

Section 17: Marital Status

Section 17.3.0.0 – Cohabitant(s)
Section 17: Marital Status
Cohabitant Summary
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 with for reasons of convenience
(e.g. a roommate). If applicable, complete the following about your cohabitant. If your
cohabitant was born outside the U.S., provide citizenship information.
Cohabitant(s)
#
Full name
1 Harris, Nancy P(IO)

Actions
Edit

Delete

17.3.0.2
Do you have an additional cohabitant to report?
□ Yes □ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – Applicant will check Yes or No to 17.3.0.2 and
click “Save” If the applicant answers “Yes”, they will go to Section 17.3.1.0,
Cohabitant Detail. If they check “No” they will proceed to Section 18.0.0.0.

Section 17: Marital Status

Section 17.3.1.0 – Cohabitant Detail
Section 17: Marital Status
Cohabitant Detail
You have indicated that you currently have a cohabitant
17.3.1.1
Provide the cohabitant full name.
Name
Last Name:
First Name:
Middle Name:
Suffix:
17.3.1.2
Provide the cohabitant date of birth.
Month/Day/Year
Est.
/

/

17.3.1.3
Provide the cohabitant place of birth.
City:
State:
Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If a country is selected indicating foreign birth
proceed to section 17.3.2.0, if not proceed to section 17.3.3.0

Section 17: Marital Status

Section 17.3.2.0 – Foreign born cohabitant detail
Section 17: Marital Status
Foreign Born Cohabitant Detail
17.3.2.1
For your foreign born cohabitant, indicate one type of documentation that he or she
possesses and the document number.
□ FS 240 or 545
□ DS 1350
□ U.S. Citizenship certificate
□ U.S. Passport (current or most recent)
□ Alien registration
□ U.S. Naturalization certificate
□ None (Provide explanation)
□ Other (Provide explanation)
Explanation:

17.3.2.2
Provide document number.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 17.3.3.0

Section 17: Marital Status

Section 17.3.3.0 – Cohabitant Detail Continued
Section 17: Marital Status
Cohabitant Detail Continued
17.3.3.1
Provide your cohabitant’s U.S. Social Security Number.
□ Not applicable
-

-

17.3.3.2
Provide other names used by your cohabitant (such as maiden names, names by other
marriage, etc., and provide dates each name was used).
□ Not applicable
#

Name

Maiden

Dates used

Name
Last
Name:
Maiden

First
Name:

1.

name?

Middle
Name:
Suffix:
17.3.3.3
Provide your cohabitant’s country(ies) of citizenship.
#

Country

1.
17.3.3.4
Provide date cohabitation began.
Month/Day/Year
/

Est.

/

Add Optional Comment

Save

Reset this Screen

Section 17: Marital Status

Date

Month/Year

From:

/

To:

/

Est./Pres.

Electronic Form Navigation Note – At save proceed to Section 17.3.0.0
Cohabitant Summary

Section 17: Marital Status

Section 18 SF86 “Relatives”
Section 18.0.0.0 - Relatives Initial Screen
Section 18: Relatives
Select each type of relative applicable to you, regardless if they are living or deceased.
(An opportunity will be provided to list multiple relatives for each type.)
18.0.0.1
Check all that apply.
□ Mother
□ Father
□ Stepmother
□ Stepfather
□ Foster parent
□ Child (including adopted/foster)
□ Stepchild
□ Brother
□ Sister
□ Stepbrother
□ Stepsister
□ Half-brother
□ Half-sister
□ Father-in-law
□ Mother-in-law
□ Guardian
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – Applicant will select checkboxes for all
pertinent relative types and select “Save”, and proceed to Screen 18.2.0.0,
Relative Detail.

Section 18: Relatives

Section 18.1.0.0 - Relatives Summary Screen
Section 18: Relatives
Summary
Summary of Relatives
# Relationship type

Full name

Actions

1 Mother

Miller, Mary S(IO)

Edit

Delete

2 Father

Miller, Gary Paul

Edit

Delete

18.1.0.1
Do you have an additional relative to enter?
□ Yes □ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 18.2.0.0, if no
proceed to Section 19.0.0.0.

Section 18: Relatives

Section 18.2.0.0 - Relatives Details
Section 18: Relatives
Relative Type
18.2.0.1
Provide relative type.

Electronic Form Navigation Note – Drop-down contains the following:
□Mother
□Father
□Stepmother
□Stepfather
□Foster parent
□Child (including adopted/foster)
□Stepchild
□Brother
□Sister
□Stepbrother
□Stepsister
□Half-brother
□Half-sister
□Father-in-law
□Mother-in-law
□Guardian
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” continue to 18.2.1.0.
If relative type equal to “Mother”, capture “Mothers Maiden Name” if applicable
moved from section 6 of the 2008 SF86.

Section 18: Relatives

Section 18.2.1.0 - Relative Details
Section 18: Relatives
Relative Details
18.2.1.1
Provide your relative’s full name.
Name
Last Name:
First Name:
Middle Name:
Suffix:
18.2.1.2
Provide your relative’s date of birth.
Month/Day/Year
/

Est.

/

18.2.1.3
Provide your relative’s place of birth.
City:
State:
Country:
18.2.1.4
Provide your relative’s country(ies) of citizenship.
#
Country
1.
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save”
If applicant relative type is “Mother” proceed to Section 18.3.0.0 “Mothers Maiden
Name”
Section 18: Relatives

If immediate family members (defined as spouse, parents, siblings, half-siblings,
step-siblings, children, step-children proceed to Section 18.4.0.0 “other names
used”.
If not an immediate family member proceed to Section 18.5.0.0.

Section 18: Relatives

Section 18.3.0.0 – Mother’s Maiden Name
Section 18: Relatives
Relative Details
18.3.0.1
Provide your mother’s maiden name. (□ same as listed)
Name
Last Name:
First Name:
Middle Name:
Suffix:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 18.4.0.0,
relatives “other names used”.

Section 18: Relatives

Section 18.4.0.0 - Relative Details
Section 18: Relatives
Immediate Family member Other Names Used
18.4.0.1
Has this relative used any other names?

□ Yes □ No

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 18.4.1.0, if “No”
proceed to Section 18.5.0.0

Section 18: Relatives

Section 18.4.0.0 - Relative Other Names Used Summary
Section 18: Relatives
Relative Other Names Used
#

Time period

Name

Actions

1 From 03/2001 To Present Danger

Edit

Delete

2 From 02/1979 To 12/1999 Jim

Edit

Delete

18.4.0.2
Has this relative used any additional names?
□ Yes □ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 18.4.1.0, if “No”
proceed to Section 18.5.0.0

Section 18: Relatives

Section 18.4.1.0 - Relative Other Names Used Detail
Section 18: Relatives
Relative Other Names Used Detail
Provide other names used and the period of time that your relative used them (such as
maiden name by a former marriage, former name, alias, or nickname).
18.4.1.1
Last name:
First name:
Middle name:
Suffix:
18.4.1.2
Maiden name?
□ Yes
□ No
18.4.1.3
Date

Month/Year

From:

/

To:

/

Est./Pres.

18.4.1.4
Provide the reason(s) why the name changed.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 18.4.0.0,
summary.

Section 18: Relatives

Section 18.5.0.0 - Relative Deceased
Section 18: Relatives
Relative Details
18.5.0.1
Is your relative deceased?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note –
If “Yes” for deceased
AND the relative was born in the U.S.
AND the relative is a U.S. citizen proceed to Section 18.1.0.0.
If “Yes” for deceased,
AND the relative is type mother, father, brother, sister, child, stepmother,
stepfather, stepchild, half-brother, half-sister
AND the relative was born outside the U.S.
AND the relative is U.S. citizen proceed to Section 18.9.0.0.
If “Yes” for deceased,
AND the relative was born outside the U.S.
AND the relative is a NOT a U.S. citizen proceed to Section 18.1.0.0.
If “No” proceed to Section 18.6.0.0.

Section 18: Relatives

Section 18.6.0.0 – Relative Current Address Details
Section 18: Relatives
Relative Current Address
18.6.0.1
Provide your relative’s current address.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 18.7.0.0. if
foreign country is provided, else proceed to 18.9.0.0.

Section 18: Relatives

18.7.0.0 Foreign Relative APO/FPO
Section 18: Relatives
APO/FPO
18.7.0.1
Does this relative have an APO/FPO address?
□ Yes
□ No
□ I don’t know
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 18.8.0.0,
If “No” or “I don’t know” proceed to:
18.1.0.0. - If relative indicated U.S. Citizen and Place of birth in the U.S.
18.9.0.0 - If they indicate U.S. Citizenship and place of birth outside the U.S.
18.10.0.0 - If relative indicates U.S. is not their country of citizenship and their
relative has a U.S. address (No country entered in country field).
18.11.0.0 - If relative indicates U.S. is not their country of citizenship and their
relative has a foreign address (Country present in country field).

Section 18: Relatives

18.8.0.0 Foreign Relative APO/FPO Details
Section 18: Relatives
APO/FPO Details
18.8.0.1
Provide you relative’s APO/FPO address.
Street
Address/Unit/Duty
Location:
City or Post Name:
. Provide State for ports in the United States; or Country locations
State:

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 18.13.0.0.
If relative indicated U.S. Citizen and Place of birth in the U.S. at “Save” return to
18.1.0.0.
If they indicate U.S. Citizenship and place of birth outside the U.S., proceed to
Section 18.9.0.0 Relative U.S. Citizenship Detail.
If relative indicates U.S. is not their country of citizenship and their relative has a
U.S. address (No country entered in country field), proceed to Section 18.10.0.0
Relative Foreign Citizenship Detail.
If relative indicates U.S. is not their country of citizenship and their relative has a
foreign address (Country present in country field), proceed to Section 18.11.0.0
Foreign Relative Detail.

Section 18: Relatives

Section 18.9.0.0 - Relative U.S. Citizenship Documentation
Section 18: Relatives
Relative U.S. Citizenship
18.9.0.1
Provide one type of citizenship documentation and document number below:
□ FS 240 or 545
□ DS 1350
□ U.S. Citizenship certificate
□ U.S. Naturalization certificate
□ U.S. Passport
□ None (Provide explanation)
□ Other (Provide explanation)
Explanation:

18.9.0.2
Provide the document number.

18.9.0.3
Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At Save proceed to Page 18.1.0.0, Relatives
Summary.

Section 18: Relatives

Section 18.10.0.0 - Relative Foreign Citizenship Documentation
Section 18: Relatives
Relative Foreign Citizenship
18.10.0.1
Provide type of documentation he or she possesses to support U.S. residence:
□ U.S. Alien Registration
□ U.S. Visa
□ Other (Provide explanation)
Explanation

18.10.0.2
Provide the document number.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 18.11.0.0,

Section 18: Relatives

Section 18.11.0.0 – Foreign Relative
Section 18: Relatives
Relative Foreign Citizenship
18.11.0.1
Provide approximate date of first contact.
Date
Month/Year
Est.
From:

/

□

18.11.0.2
Provide approximate date of last contact.
Date
Month/Year
Est./Pres.
From:

/

18.11.0.3
Provide methods of contact (check all that apply)
□ In person
□ Telephone
□ Electronic (Such as e-mail, texting, chat rooms, etc)
□ Written correspondence
□ Other (Provide explanation)
Explanation:

18.11.0.4
Provide approximate frequency of contact:
□ Daily
□ Weekly
□ Monthly
□ Quarterly
□ Annually
□ Other (Provide explanation)
Explanation:

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to 18.12.0.0
Section 18: Relatives

18.12.0.0 Foreign Relative Employer
Section 18: Relatives
Relative’s Employer
18.12.0.1
Provide name of current employer, or provide the name of their most recent employer if
not currently employed (if known).
□ I don’t know

18.12.0.2
Provide the address of current employer, or provide the address of their most recent
employer if not currently employed.
□ I don’t know
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to section 19.13.0.0

Section 18: Relatives

18.13.0.0 Foreign Relative Foreign Military Affiliation
Section 18: Relatives
Relative Foreign Military Affiliation
18.13.0.1
Is this relative affiliated with a foreign government, military, security, defense industry,
foreign movement, or intelligence service?
□ Yes
□ No
□ I don't know
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “No” proceed to Section 18.1.0.0, if “Yes”
proceed to Section 18.14.0.0

Section 18: Relatives

18.14.0.0 Foreign Contact Foreign Military Affiliation Detail
Section 15: Relatives
Relative Foreign Military Affiliation Detail
18.14.0.1
Describe the relative’s relationship with the foreign government, military, security,
defense industry, foreign movement, or intelligence service.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 18.1.0.0

Section 18: Relatives

Section 19 SF86 “Foreign Contacts”
Section 19.0.0.0 - Foreign Contacts Initial Screen
Section 19: Foreign Contacts
A foreign national is defined as any person who is not a citizen or national of the U.S.
19.0.0.1
Do you have, or have you had, close and/or continuing contact with a foreign national
within the last seven (7) years with whom you, or your spouse, or cohabitant are bound
by affection, influence, common interests, and/or obligation? Include associates as well
as relatives, not previously listed in Section 18.
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “No” proceed to Section 20a.0.0, if “Yes”
proceed to Section 19.2.0.0

Section 19: Foreign Contacts

Section 19.1.0.0 - Foreign Contact Summary Screen
Section 19: Foreign Contacts
Summary
Summary of Foreign Contacts
# Full Name

Edit

Delete

19.1.0.1
Do you have, or have you had, close and/or continuing contact with any additional
foreign national within the last seven (7) years with whom you, or your spouse, or
cohabitant are bound by affection, influence, common interests, and/or obligation?
Include associates as well as relatives, not previously listed in Section 18.
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “No” proceed to Section 20a, if “Yes”
proceed to Section 19.2.0.0.

Section 19: Foreign Contacts

19.2.0.0 Foreign Contact Detail
Section 19: Foreign Contacts
Detail
You indicated that you have, or have had, close and/or continuing contact with a foreign
national.
19.2.0.1
Provide the full name of the foreign national, if known
□ I don’t know
Name
Last Name:
First Name:
Middle Name:
Suffix:
19.2.0.2
Explanation if name is unknown:

19.2.0.3
Provide approximate date of first contact.
Date
Month/Year
Est.
/

□

19.2.0.4
Provide approximate date of last contact.
Date
Month/Year
Est./Pres.
/
19.2.0.5
Provide methods of contact (check all that apply)
□ In person
□ Telephone
□ Electronic (Such as e-mail, texting, chat rooms, etc)
□ Written correspondence
□ Other (Provide explanation)
Explanation:

Section 19: Foreign Contacts

19.2.0.6
Provide approximate frequency of contact
□ Daily
□ Weekly
□ Monthly
□ Quarterly
□ Annually
□ Other (Provide explanation)
Explanation:

19.2.0.7
Provide the nature of relationship (select all that apply)
□ Professional or Business
□ Personal (Such as family ties, friendship, affection, common interests, etc)
□ Obligation (Provide explanation)
□ Other (Provide explanation)
Explanation:

19.2.0.8
Provide other names and/or nicknames, as appropriate:
#
Name

Actions

Name
Last Name:
1.

First Name:

Delete

Middle Name:
Suffix:
Add A Blank Entry

19.2.0.9
Provide country(ies) of citizenship
#
Country
1.

Section 19: Foreign Contacts

19.2.0.10
Provide date of birth.
□ I don’t know
Month/Day/Year
/

Est.

/

19.2.0.11
Provide place of birth.
□ I don’t know
City:
Country:
19.2.0.12
Provide current address.
□ I don’t know
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
Add Optional Comment

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U.S. proceed to section 19.3.0.0, if U.S. address is provided proceed to 19.5.0.0

Section 19: Foreign Contacts

19.3.0.0 Foreign Contact APO/FPO
Section 19: Foreign Contacts
APO/FPO
19.3.0.1
Does this person have an APO/FPO address?
□ Yes
□ No
□ I don’t know
Add Optional Comment

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“I don’t know” proceed to Section 19.5.0.0

Section 19: Foreign Contacts

19.4.0.0 Foreign Contact APO/FPO Details
Section 19: Foreign Contacts
APO/FPO Details
19.4.0.1
Provide the foreign national’s APO/FPO address.
Street
Address/Unit/Duty
Location:
City or Post Name:
Provide State for ports in the United States, or Country location.
State:

Zip Code:

Country:
Add Optional Comment

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Section 19: Foreign Contacts

19.5.0.0 Foreign Contact Employer
Section 19: Foreign Contacts
Contact’s Employer
19.5.0.1
Provide the name of the foreign national’s current employer, or provide the name of their
most recent employer if not currently employed.
□ I don’t know

19.5.0.2
Provide the address of the foreign national’s current employer, or provide the address of
their most recent employer if not currently employed.
□ I don’t know
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
Add Optional Comment

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Section 19: Foreign Contacts

19.6.0.0 Foreign Contact Foreign Military Affiliation
Section 19: Foreign Contacts
Contact Foreign Military Affiliation
19.6.0.1
Is this foreign national affiliated with a foreign government, military, security, defense
industry, or intelligence service?
□ Yes
□ No
□ I don't know
Add Optional Comment

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proceed to Section 19.7.0.0

Section 19: Foreign Contacts

19.7.0.0 Foreign Contact Foreign Military Affiliation Detail
Section 19: Foreign Contacts
Contact Foreign Military Affiliation Detail
19.7.0.1
Describe the contact’s relationship with the foreign government, military, security,
defense industry, or intelligence service.

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Section 19: Foreign Contacts

Section 20a SF86 “Foreign Activities”
Section 20a.1.0.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
20a.1.0.1
Have you, your spouse, cohabitant, or dependent children EVER had any foreign
financial interests (such as stocks, property, investments, bank accounts, ownership of
corporate entities, corporate interests or businesses) in which you or have direct control
or direct ownership? (Exclude financial interests in companies or diversified mutual
funds that are publicly traded on a U.S. exchange.)
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.2.0.0

Section 20a: Foreign Activities

Section 20a.1.1.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
You responded ‘Yes’ to you, your spouse, cohabitant, or dependent children having
EVER had any foreign financial interests (such as stocks, property, investments, bank
accounts, ownership of corporate entities, ownership of corporate entities, corporate
interests or businesses) in which you or they have direct control or direct ownership
(Exclude financial interests in companies or diversified mutual funds that are publicly
traded on a U.S. exchange).
20a.1.1.1
Specify: (check all that apply)
□ Yourself
□ Spouse
□ Cohabitant
□ Dependent children
20a.1.1.2
Provide the type of financial interest.

20a.1.1.3
Provide the date acquired.
Month/Day/Year
/

Est.

/

20a.1.1.4
Provide how the financial interest was acquired (such as purchase, gift, etc.)

20a.1.1.5
Provide the cost (in U.S. dollars) at time of acquisition.
□ Estimated

20a.1.1.6
Provide the current value (in U.S. dollars) or the value at the time control or ownership
was sold, lost or otherwise disposed of.
□ Estimated

Section 20a: Foreign Activities

20a.1.1.7
Provide the date control or ownership was relinquished.
Not applicable:
Month/Day/Year
/

Est.

/

20a.1.1.8
Provide explanation of how interest control or ownership was sold, lost or otherwise
disposed of.

Add Optional Comment

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Section 20a: Foreign Activities

Section 20a.1.2.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Co-owners
20a.1.2.0
Are there any co-owners of this foreign financial interest?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.1.5.0

Section 20a: Foreign Activities

Section 20a.1.3.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Co-owners Detail
You responded ‘Yes’ to there being co-owners; provide the name, address, citizenship,
and relationship of the co-owner(s).
20a.1.3.1
Provide full name of co-owner.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20a.1.3.2
Provide co-owner current address.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20a.1.3.3
Provide co-owner’s country(ies) of citizenship.
#
Country
1.
20a.1.3.4
Provide the nature of your relationship with the co-owner.

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Section 20a: Foreign Activities

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Section 20a: Foreign Activities

Section 20a.1.4.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Co-owners Summary
Summary of Co-owners
# Relationship type Full name

Edit

Delete

20a.1.4.1
Are there any additional co-owners of this foreign financial interest?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.1.5.0

Section 20a: Foreign Activities

Section 20a.1.5.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests Summary
#

Type of financial interest

1. Stock in ABC International

Amount of funds (in U.S. dollars)
$150,000

Actions
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20a.1.5.1
Do you, your spouse, cohabitant, or dependent children have any additional foreign
financial interests?
□ Yes
□ No
Add Optional Comment

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20a.1.1.0. If “No” proceed to Section 20a.2.0.0:

Section 20a: Foreign Activities

Section 20a.2.0.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Controlled on Your Behalf
20a.2.0.1
Have you, your spouse, cohabitant, or dependent children EVER had any foreign
financial interests that someone controlled on your behalf?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.3.0.0

Section 20a: Foreign Activities

Section 20a.2.1.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Controlled on Your Behalf Detail
You responded ‘Yes’ to you, your spouse, cohabitant, or dependent children having
EVER had any foreign financial interests that someone controlled on your behalf.
20a.2.1.1
Specify: (check all that apply)
□ Yourself
□ Spouse
□ Cohabitant
□ Dependent children
20a.2.1.2
Provide the type of financial interest.

20a.2.1.3
Provide the name of the individual who controls this financial interest on your behalf.
Last Name:
First Name:
20a.2.1.4
Provide this individual’s relationship to you.

20a.2.1.5
Provide the date this financial interest was acquired.
Month/Day/Year
Est.
/

/

20a.2.1.6
Provide details regarding how it was acquired (such as purchase, gift, etc.).

20a.2.1.7
Provide the cost (in U.S. dollars) at time of acquisition.
□ Estimated

Section 20a: Foreign Activities

20a.2.1.8
Provide the current value (in U.S. dollars) or value at the time interest was sold, lost or
otherwise disposed of.
□ Estimated

20a.2.1.9
Provide the date interest was sold, lost or otherwise disposed of.
Not applicable:
Month/Day/Year
/

Est.

/

20a.2.1.10
Provide explanation if interest was sold, lost or otherwise disposed of

Add Optional Comment

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Section 20a: Foreign Activities

Section 20a.2.2.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Controlled on Your Behalf Co-Owners
20a.2.2.1
Are there any co-owners of the foreign financial interest controlled on your behalf?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.2.5.0.

Section 20a: Foreign Activities

Section 20a.2.3.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Controlled on Your Behalf Co-Owners Detail
You responded ‘Yes’ to there being any co-owners.
20a.2.3.1
Provide the full name of the co-owner.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20a.2.3.2
Provide the current address of the co-owner.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20a.2.3.3
Provide the co-owner’s country(ies) of citizenship.
#
Country
1.
20a.2.3.4
Provide your relationship with the co-owner.

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Section 20a: Foreign Activities

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Section 20a: Foreign Activities

Section 20a.2.4.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Controlled on Your Behalf Summary
Summary of Co-owners
# Relationship type Full name

Edit

Delete

20a.2.4.1
Are there any additional co-owners for this foreign financial interest controlled on your
behalf to report?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.2.5.0

Section 20a: Foreign Activities

Section 20a.2.5.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests Controlled on Your
Behalf Summary
#

Type of financial interest

1. Stock in ABC International

Amount of funds (in U.S. dollars)
$150,000

Actions
Edit

Delete

20a.2.5.1
Do you, your spouse, cohabitant, or dependent children have any additional foreign
financial interests controlled on your behalf?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.3.0.0:

Section 20a: Foreign Activities

Section 20a.3.0.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Real Estate
20a.3.0.1
Have you, your spouse, cohabitant, or dependent children EVER owned, or do you
anticipate owning, or plan to purchase real estate in a foreign country?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.4.0.0

Section 20a: Foreign Activities

Section 20a.3.1.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Real Estate Detail
You responded ‘yes’ to you, your spouse, cohabitant, or dependent children having ever
owned, or anticipate owning, or planning to purchase real estate in a foreign country.
20a.3.1.1
Specify: (check all that apply)
□ Yourself
□ Spouse
□ Cohabitant
□ Dependent children
20a.3.1.2
Provide the type of real estate property (such as home, business, etc.).

20a.3.1.3
Provide the location/address of property.
Street:
City:
Country:
20a.3.1.4
Provide the date to be acquired.
Month/Day/Year
/

Est.

/

20a.3.1.5
Provide how the foreign real estate is to be acquired (such as purchase, gift, etc.).

20a.3.1.7
Provide the cost (in U.S. dollars) expected at time of acquisition.
□ Estimated

Add Optional Comment

Section 20a: Foreign Activities

Save

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Section 20a: Foreign Activities

Section 20a.3.2.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Real Estate – Co-Owners
20a.3.2.1
Are there any co-owners of this foreign real estate?
□ Yes
□ No
Add Optional Comment

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proceed to 20a.3.3.0.

Section 20a: Foreign Activities

Section 20a.3.3.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Real Estate – Co-Owner Detail
You responded ‘Yes’ to there being any co-owners;.
20a.3.3.1
Provide the full name of the co-owner.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20a.3.3.2
Provide the co-owner’s current address.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20a.3.3.3
Provide the co-owner’s country(ies) of citizenship.
#
Country
1.
20a.3.3.4
Provide the nature of your relationship with the co-owner.

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Section 20a: Foreign Activities

Section 20a.3.4.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Real Estate – Co-Owner Summary
Summary of Co-owners
# Relationship type Full name

Edit

Delete

20a.3.4.1
Are there any additional co-owners of this foreign real estate?
□ Yes
□ No
Add Optional Comment

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“No” proceed to Section 20a.3.5.0

Section 20a: Foreign Activities

Section 20a.3.5.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Real Estate – Summary
#

Property City and Country

1. Kandahar, Afghanistan

Amount of funds (in U.S. dollars)
$1,500,000

Actions
Edit

Delete

20a.3.5.1
Do you have an additional instance of you, your spouse, cohabitant, or dependent
children EVER having owned, or anticipate owning, or planning to purchase real estate
in a foreign country?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.4.0.0

Section 20a: Foreign Activities

Section 20a.4.0.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit
20a.4.0.1
As a U.S. citizen, have you, your spouse, cohabitant, or dependent children received in
the past seven (7) years, or are eligible to receive in the future, any educational, medical,
retirement, social welfare, or other such benefit from a foreign country?
□ Yes
□ No
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Section 20a: Foreign Activities

Section 20a.4.1.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit Detail
You responded ‘Yes’ that as a U.S. citizen, have you, your spouse, cohabitant, or
dependent children received in the past seven (7) years, or are eligible to receive in the
future, any educational, medical, retirement, social welfare, or other such benefit from a
foreign country;
20a.4.1.1
Specify: (check all that apply)
□ Yourself
□ Spouse
□ Cohabitant
□ Dependent children
20a.4.1.2
Provide the type of benefit.
Electronic Form Navigation Note –
Drop-down contains:
Educational
Medical
Retirement
Social Welfare
Other such benefit (Provide explanation)
Explanation:

20a.4.1.3
Provide the frequency of the benefit.
Electronic Form Navigation Note –
Drop-down contains:
Onetime benefit
Future benefit
Continuing benefit
Other (Provide explanation)
Explanation:

Add Optional Comment

Section 20a: Foreign Activities

Save

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If applicant selects “Onetime benefit” proceed to Section 20a.4.2.0
If applicant selects “Future benefit” proceed to Section 20a.4.3.0
If applicant selects “Continuing benefit” or “Other Benefit” proceed to Section
20a.4.4.0

Section 20a: Foreign Activities

Section 20a.4.2.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit Detail – Onetime Benefit
You have indicated that you, your spouse, cohabitant, or dependent children received a
onetime benefit from a foreign country
20a.4.2.1
Provide the date the benefit was received.
Month/Day/Year
Est.
/

/

20a.4.2.2
Provide the name of the country providing the benefit.

20a.4.2.3
Provide the total value (in U.S. dollars) of the benefit received.
□ Estimated

20a.4.2.4
Provide the reason this benefit was received.

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Section 20a: Foreign Activities

Section 20a.4.3.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit Detail – Future Benefit
You have indicated that you, your spouse, cohabitant, or dependent children expect to
receive a benefit from a foreign country.
20a.4.3.1
Provide the date the benefit will begin.
Month/Day/Year
Est.
/

/

20a.4.3.2
Provide the frequency the benefit will be received.
Frequency:
Electronic Form Navigation Note –
Contents of Drop-Down:
Annually
Quarterly
Monthly
Weekly
Other (Provide explanation)
Explanation:

20a.4.3.3
Provide the name of the country providing this benefit.

20a.4.3.4
Provide the value (in U.S. dollars) of the benefit to be received.
□ Estimated

20a.4.3.5
Provide the reason this benefit will be received.

Add Optional Comment

Section 20a: Foreign Activities

Save

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Section 20a: Foreign Activities

Section 20a.4.4.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit Detail – Continuing Benefit
You have indicated that you, your spouse, cohabitant, or dependent children receive a
continuing or other benefit from a foreign country.
20a.4.4.1
Provide the date the benefit began.
Month/Day/Year
Est.
/

/

Provide the date the benefit is expected to end.
Month/Day/Year
Est.
/

/

20a.4.4.2
Provide the frequency that this benefit is received.
Frequency:
Electronic Form Navigation Note –
Contents of Drop-Down:
Annually
Quarterly
Monthly
Weekly
Other (Provide explanation)
Explanation:

20a.4.4.3
Provide the name of the country providing the benefit.

20a.4.4.4
Provide the total value (in U.S. dollars) of benefit.
□ Estimated

20a.4.4.5

Section 20a: Foreign Activities

Provide the reason that benefit is being received.

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Section 20a: Foreign Activities

Section 20a.4.5.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit Detail – Continued
20a.4.5.1
As a result of this benefit are you, your spouse, your cohabitant, or dependent children
obligated in any way to this foreign country?
□ Yes (Provide explanation)
□ No
Explanation:

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Section 20a: Foreign Activities

Section 20a.4.6.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign Benefit Detail – Summary
#
1.

Type of Benefit
ABC International Medical
Insurance

Amount of funds (in U.S. dollars)
$1,500

Actions
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20a.4.6.1
Do you, your spouse, cohabitant, or dependent children receive any additional benefits
from a foreign country?
□ Yes
□ No
Add Optional Comment

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proceed to Section 20a.5.0.0

Section 20a: Foreign Activities

Section 20a.5.0.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign National Support
20a.5.0.1
Have you EVER provided financial support for any foreign national?
□ Yes
□ No
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proceed to Section 20b.0.0.0

Section 20a: Foreign Activities

Section 20a.5.1.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign National Support Detail
You responded ‘Yes’ to providing financial support for any foreign national.
20a.5.1.1
Provide the name of the foreign national you support or have supported financially.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20a.5.1.2
Provide the address of the foreign national listed above.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20a.5.1.3
Provide the nature of your relationship with the foreign national listed above.

20a.5.1.4
Provide the amount (in U.S. dollars) of all financial support provided.
□ Estimated

20a.5.1.5
Provide the frequency of your support.

20a.5.1.6

Section 20a: Foreign Activities

Provide this foreign national’s country(ies) of citizenship.
#
Country
1.
Add Optional Comment

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Section 20a: Foreign Activities

Section 20a.5.2.0 – Foreign Activities
Section 20a: Foreign Activities: Foreign Financial Interests
Foreign National Support Summary
#

Foreign National

1. John J. Doe

Amount of funds (in U.S. dollars)
$150,000

Actions
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20a.5.2.1
Have you additionally provided financial support for any foreign national?
□ Yes
□ No
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proceed to Section 20b.0.0.0

Section 20a: Foreign Activities

Section 20b SF86 “Foreign Business, Professional Activities, and Foreign
Government Contacts”
Section 20b.1.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Business/Organization Advice / Support
20b.1.0.1
Have you in the past seven (7) years provided advice or support to any individual
associated with a foreign business or other foreign organization that you have not
previously listed as a former employer? (Answer “No” if all your advice or support was
authorized pursuant to official U.S. Government business.)
□ Yes
□ No
Add Optional Comment

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.1.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Business/Organization Advice / Support - Detail
You responded ‘Yes’ to having in the past seven (7) years provided advice or support to
any individual associated with a foreign business or other foreign organization that you
have not previously listed as a former employer.
20b.1.1.1
Provide a description of advice/support provided.

20b.1.1.2
Provide the name of the individual to whom advice or support was provided.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20b.1.1.3
Provide the name of the foreign organization or foreign business with whom the
individual is associated.

20b.1.1.4
Provide the country of origin for the organization or business.

20b.1.1.5
Provide the date(s) during which this advice or support was provided.
Date
Month/Year
Est./Pres.
From:

/

To:

/

Sections 20b: Foreign Business, Professional and Government Contacts

20b.1.1.6
Describe what compensation, if any, was provided for your service.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.1.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Business/Organization Advice/Support - Summary

#

Summary of Advice/Support Activities
Dates of activity
Organization(s)
Actions

1 From 03/1978 To 01/1985 ABC International

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20b.1.2.1
Have you in the past seven (7) years provided advice or support to any other individual
associated with a foreign business or other foreign organization that you have not
previously listed as a former employer? (Answer “No” if all your advice or support was
authorized pursuant to official U.S. Government business.)
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.2.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Consulting
For this question, “Immediate Family” means your spouse, parents, step-parents, siblings,
half and step-siblings, children, step-children, and cohabitant.
20b.2.0.1
Have you, your spouse, cohabitant, or any member of your immediate family in the past
seven (7) years been asked to provide advice or serve as a consultant, even informally,
by any foreign government official or agency? (Answer “No’ if all the advice or support
was authorized pursuant to official U.S. Government business.)
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.2.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Consulting - Detail
You responded ‘Yes’ to you, your spouse, cohabitant, or any member of your immediate
family having in the past seven (7) years been asked to provide advice or serve as a
consultant, even informally, by any foreign government official or agency.
20b.2.1.1
Provide the name of the government official.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20b.2.1.2
Provide the name of the agency.

Provide the country with which the government official or agency is affiliated.

20b.2.1.3
Provide the date of the request.
Month/Year

Est.

/
20b.2.1.4
Provide the circumstances of request.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.2.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Consulting - Summary
Summary of Consultations
# Date of request/consultation Location
1 From 01/1990 To 02/1995

Mexico

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20b.2.2.1
Have you, your spouse, cohabitant, or any member of your immediate family in the past
seven (7) years been asked to provide advice or serve as a consultant, even informally,
by any other foreign government official or agency? (Answer ‘No’ if all the advice or
support was authorized pursuant to official U.S. Government business.)
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.3.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign National Job Offer
20b.3.0.1
Has any foreign national in the past seven (7) years offered you a job, asked you to
work as a consultant, or consider employment with them?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.3.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign National Job Offer - Detail
You responded ‘Yes’ to any foreign national having in the past seven (7) years offered
you a job, asked you to work as a consultant, or consider employment with them.
20b.3.1.1
Provide the name of the foreign national who made the offer.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20b.3.1.2
Provide a description of the position offered.

20b.3.1.3
Provide the date when this offer was extended.
Month/Year
Est.
/
20b.3.1.4
Provide the location where this occurred.
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20b.3.1.5
Did you accept the offer?
□ Yes
□ No
Sections 20b: Foreign Business, Professional and Government Contacts

Provide explanation.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.3.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign National Job Offer – Summary
Summary of Job Offers
# Date of offer Location Actions
1

01/2009

India

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20b.3.2.1
Has any additional foreign national, in the past seven (7) years, offered you a job, asked
you to work as a consultant, or consider employment with them?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.4.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Other Foreign Business Ventures
20b.4.0.1
Have you in the past seven (7) years been involved in any other type of business venture
with a foreign national not described above (own, co-own, serve as business consultant,
provide financial support, etc.)?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.4.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Other Foreign Business Ventures - Detail
You responded ‘Yes’ to having in the past seven (7) years been involved in any other
type of business venture with a foreign national not described above.
20b.4.1.1
Provide the full name of this foreign national.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20b.4.1.2
Provide the full current address of this foreign national.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20b.4.1.3
Provide the citizenship(s) of this foreign national.
#
Country
1.
20b.4.1.4
Provide a description of the business venture.

20b.4.1.5
Provide your relationship to this foreign national.

Sections 20b: Foreign Business, Professional and Government Contacts

20b.4.1.6
Provide the length of time you have been involved in the business venture.
Date
Month/Year
Est./Pres.
From:

/

To:

/

20b.4.1.7
Provide the nature of association with this business venture.

20b.4.1.8
Provide the position you held.

20b.4.1.9
Provide the service you provided.

20b.4.1.10
Provide the financial support involved.

20b.4.1.11
Provide a description of what compensation was provided for your service.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.4.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Other Foreign Business Ventures - Summary
Summary of Other Business Ventures
# Date of Business Venture Location
Actions
1 From 01/1990 To 02/1995 North Korea

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20b.4.2.1
Have you, in the past seven (7) years, been involved in any other type of business
venture with a foreign national not described above (own, co-own, serve as business
consultant, provide financial support, etc.)?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.5.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Conferences, Trade shows, Seminars, and Meetings
20b.5.0.1
Have you in the past seven (7) years attended or participated in any conferences, trade
shows, seminars, or meetings outside the U.S.? (Do not include those you attended or
participated in on official business for the U.S. government.)
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.5.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Conferences, Trade shows, Seminars, and Meetings - Detail
You responded ‘Yes’ to in the past seven (7) years having attended or participated in
any conferences, trade shows, seminars, or meetings outside the U.S.
20b.5.1.1
Provide the name and description of event.

20b.5.1.2
Provide the name of sponsoring organization.

20b.5.1.3
Provide the city where the event was held.

20b.5.1.4
Provide the country where the event was held.

20b.5.1.5
Provide the dates for the event.
Date
Month/Year
From:

/

To:

/

Est./Pres.

20b.5.1.6
Provide the purpose of the event.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.5.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Conferences, Trade shows, Seminars, and Meetings – Subsequent Contact
20b.5.2.1
Was there any subsequent contact with any foreign nationals as a result of the event?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.5.3.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Conferences, Trade shows, Seminars, and Meetings – Subsequent Contact
Details
20b.5.3.1
You responded ‘Yes’ to there having been subsequent contact with any foreign nationals
as a result of the event.
Provide explanation.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.5.4.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Conferences, Trade shows, Seminars, and Meetings – Subsequent Contact
Summary
Summary of subsequent contacts
#
Contact Name
Actions
1 Doe, John J.

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20b.5.4.1
Do you have another subsequent contact to report for this event?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.5.5.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Conferences, Trade shows, Seminars, and Meetings - Summary
Summary of events
#
Date of event

Location

1 From 06/1996 To 07/1996 Russia

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20b.5.5.1
Have you in the past seven (7) years, attended or participated in any additional
conferences, trade show, seminars, or meetings outside the U.S.? (Do not include those
you attended or participated in on official business for the U.S. government).
□ Yes
□ No
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proceed to Section 20b.6.0.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.6.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Government Contact
For Section 20b, “Immediate Family” means your spouse, parents, step-parents, siblings,
half and step-siblings, children, step-children, and cohabitant.
20b.6.0.1
Have you or any member of your immediate family in the past seven (7) years had any
contact with a foreign government, its establishment (such as embassy, consulate,
agency, military service, intelligence or security service, etc.) 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 on a U.S. passport.)
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.6.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Government Contact - Detail
You responded ‘Yes’ to you or any member of your immediate family having in the past
seven (7) years had any contact with a foreign government, its establishment (such as
embassy, consulate, agency, military service, intelligence or security service, etc.) or its
representatives, whether inside or outside the U.S.
20b.6.1.1
Provide the name of the individual involved in the contact.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20b.6.1.2
Provide the location of the contact.
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20b.6.1.3
Provide the date of contact.
Month/Year

Est.

/
20b.6.1.4
Provide the foreign government(s) involved.
#
Country
1.
Add A Blank Entry

Sections 20b: Foreign Business, Professional and Government Contacts

20b.6.1.5
Provide the type of establishment (such as embassy, consulate, agency, military service,
intelligence or security service, etc.) involved.

20b.6.1.6
Provide the names of the foreign representatives involved in contact.

20b.6.1.7
Provide the purpose/circumstances of contact.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.6.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Government Contact – Subsequent Contact
20b.6.2.1
Was there any subsequent contact initiated by you, your immediate family member, or a
representative of the foreign organization?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.6.3.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Government Contact – Subsequent Contact Detail
You responded ‘Yes’ to there having been subsequent contact initiated by you, your
immediate family member, or a representative of the foreign organization.
20b.6.3.1
Provide the purpose of the subsequent contact.

20b.6.3.2
Provide the date of most recent contact.
Month/Day/Year
Est.
/

/

20b.6.3.3
Provide plans for future contact.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.6.4.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Government Contact – Subsequent Contact Summary
Summary of subsequent contact
# Contact Name
Actions
1 Doe, John J.

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20b.6.4.1
Do you have another subsequent contact to report for this event?
□ Yes
□ No
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proceed to Section 20b.6.5.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.6.5.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Foreign Government Contact – Summary
Summary of Government Contacts
#
Date of contact
Location
1 From 04/2005 To 03/2006 Tokyo

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20b.6.5.1
Have you or any member of your immediate family in the past seven (7) years had any
additional contact with a foreign government, its establishment (such as embassy,
consulate, agency, military service, intelligence or security service, etc.) 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 on a U.S. passport).
□ Yes
□ No
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proceed to Section 20b.7.0.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.7.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Sponsorship of a Foreign National
20b.7.0.1
Have you in the past seven (7) years sponsored any foreign national to come to the U.S.
as a student, for work, or for permanent residence?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.7.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Sponsorship of a Foreign National - Detail
You responded ‘Yes’ to in the past seven (7) years having sponsored any foreign
national to come to the U.S. as a student, for work, or for permanent residence.
20b.7.1.1
Provide the name of the sponsored foreign national.
Name
Last Name:
First Name:
Middle Name:
Suffix:
20b.7.1.2
Provide the date of birth for the sponsored foreign national.
□ I don’t know
Month/Year
Est.
/
20b.7.1.3
Provide the place of birth for the sponsored foreign national.
City:
State:

Zip Code:

Country:
20b.7.1.4
Provide the current street address of the sponsored foreign national.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.

Sections 20b: Foreign Business, Professional and Government Contacts

Country:
20b.7.1.5
Provide the country(ies) of citizenship for the sponsored foreign national.
#
Country
1.
Add A Blank Entry

20b.7.1.6
Provide the name of the organization through which sponsorship was arranged, if
applicable.
Not Applicable □

20b.7.1.7
Provide the address of the organization through which sponsorship was arranged, if
applicable.
Not Applicable □
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
20b.7.1.8
Provide the dates of stay in the U.S. for the sponsored foreign national.
Date
Month/Year
Est./Pres.
From:

/

To:

/

20b.7.1.9
Provide the address of the sponsored foreign national while residing in the U.S.
Street:
City:

Sections 20b: Foreign Business, Professional and Government Contacts

State:

Zip Code:

20b.7.1.10
Provide the purpose of stay in the U.S. for the sponsored foreign national.

20b.7.1.11
Provide the purpose of your sponsorship for the sponsored foreign national.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.7.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Sponsorship of a Foreign National - Summary
Summary of sponsored foreign citizen visits
#
Dates of stay
Name of foreign citizen
1 From 01/2006 To 02/2007 Doe, John J.

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20b.7.2.1
Have you in the past seven (7) years sponsored any additional foreign national to come
to the U.S. as a student, for work, or for permanent residence?
□ Yes
□ No
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proceed to Section 20b.8.0.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.8.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Holding Foreign Political Office
20b.8.0.1
Have you EVER held political office in a foreign country?
□ Yes
□ No
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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.8.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Holding Foreign Political Office - Detail
You responded ‘Yes’ to having EVER held political office in a foreign country.
20b.8.1.1
Provide the position held.

20b.8.1.2
Provide the dates you held political office.
Date
Month/Year
Est./Pres.
From:

/

To:

/

20b.8.1.3
Provide the name of the country involved.

20b.8.1.4
Provide the reason(s) for these activities.

20b.8.1.5
Provide your current eligibility to hold political office in a foreign country.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.8.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Holding Foreign Political Office - Summary
Summary of offices held
#

Date of event

Location

1 From 06/1996 To 07/1996 Russia

Office
Held
Governor

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20b.8.2.1
Have you EVER held any additional political office in a foreign country?
□ Yes
□ No
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proceed to Section 20b.9.0.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.9.0.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Voting in a Foreign Election
20b.9.0.1
Have you EVER voted in the election of a foreign country?
□ Yes
□ No
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proceed to Section 20c.0.0.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.9.1.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Voting in a Foreign Election - Detail
You responded ‘Yes’ to having EVER voted in the election of a foreign country.
20b.9.0.1
Provide the date you voted in the foreign election.
Month/Year
Est.
/

□

20b.9.0.2
Provide the name of the country involved.

20b.9.0.3
Provide the reason(s) for these activities.

20b.9.0.4
Provide your current eligibility to vote in a foreign election.

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Sections 20b: Foreign Business, Professional and Government Contacts

Section 20b.9.2.0 - Foreign Business, Professional Activities, and Foreign
Government Contacts.
Section 20b: Foreign Activities: Foreign Business, Professional Activities, and
Foreign Government Contacts
Voting in a Foreign Election – Summary
Summary of voting
#
Dates of event

Location

1 From 06/1996 To 07/1996 Russia

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20b.9.2.1
Do you have other instances of voting in the election of a foreign country to report?
□ Yes
□ No
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proceed to Section 20c.0.0.0

Sections 20b: Foreign Business, Professional and Government Contacts

Section 20c SF86 “Foreign Countries You have Visited”
Section 20c.0.0.0 - Foreign countries you have visited
Section 20c: Foreign Activities: Foreign Countries You Have Visited
20c.0.0.1
Have you traveled outside the U.S. in the last seven (7) years?
□ Yes
□ No
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Sections 20c: Countries Visited

Section 20c.1.0.0 - Foreign countries you have visited
Section 20c: Foreign Activities: Foreign Countries You Have Visited
20c.1.0.1
Has your travel in the last seven (7) years been solely for U.S. Government business (i.e.,
no personal trips in conjunction with the official U.S. Government business)?
□ Yes
□ No
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proceed to Section 20c.2.0.0.

Sections 20c: Countries Visited

Section 20c.2.0.0 - Foreign countries you have visited
Section 20c: Foreign Activities: Foreign Countries You Have Visited
Detail
You responded ‘Yes’ to having traveled outside the U.S. in the last seven (7) years for
other than solely U.S. Government business. Provide information about all such trips
made outside the United States including personal trips made in conjunction with official
U.S. Government business.
20c.2.0.1
Provide the country visited.

20c.2.0.2
Provide the dates of your travel to this country.
Date
Month/Year
Est./Pres.
From:

/

To:

/

20c.2.0.3
Provide the total number of days involved in the visit.
□ 1-5
□ 6-10
□ 11-20
□ 21-30
□ More than 30
□ Many short trips
20c.2.0.4
Provide the purpose of the travel to this country (Check all that apply)
□ Business/professional
□ Volunteer activities
□ Education
□ Tourism
□ Trade shows, conferences, and seminars
□ Visit family or friends
□ Other
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Sections 20c: Countries Visited

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Sections 20c: Countries Visited

Section 20c.3.0.0 - Foreign countries you have visited
Section 20c: Foreign Activities: Foreign Countries You Have Visited
Detail
20c.3.0.1
While traveling to, or in this country, were you questioned, searched, or otherwise
detained (other than for normal customs requirements) by the local customs or security
service officials when entering or leaving this country?
□ Yes (Provide explanation)
□ No
Explanation:

20c.3.0.2
While traveling to or in this country, were you involved in any encounter with the police?
□ Yes (Provide explanation)
□ No
Explanation:

20c.3.0.3
While traveling to or in this country, were you contacted by, or in contact with any
person known or suspected of being involved or associated with foreign intelligence,
terrorist, security, or military organizations?
□ Yes (Provide explanation)
□ No
Explanation:

20c.3.0.4
While traveling to, or in this country, were you involved in any counterintelligence or
security issues not reported?
□ Yes (Provide explanation)
□ No
Explanation:

20c.3.0.5
While traveling to or in this country, were you contacted by, or in contact with anyone
exhibiting excessive knowledge of or undue interest in you or your job?
Sections 20c: Countries Visited

□ Yes (Provide explanation)
□ No
Explanation:

20c.3.0.6
While traveling to or in this country, were you contacted by, or in contact with anyone
attempting to obtain classified information or unclassified, sensitive information?
□ Yes (Provide explanation)
□ No
Explanation:

20c.3.0.7
While traveling to, or in this country, were you threatened, coerced, or pressured in any
way to cooperate with a foreign government official or foreign intelligence or security
service?
□ Yes (Provide explanation)
□ No
Explanation:

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Sections 20c: Countries Visited

Section 20c.4.0.0 - Foreign countries you have visited
Section 20c: Foreign Activities: Foreign Countries You Have Visited
Summary
Section 20c. Foreign Activities: Foreign Countries You Have Visited
Respond for the time frame of the last seven (7) years, beginning with the most recent
and working backwards (Do not list trips that ONLY involved travel on official U.S.
Government business, but you must include any personal trips made in conjunction with
the official U.S. Government travel).
Summary of foreign countries you have visited.
#
Time period
Country(ies) Actions
1 From 04/2007 To 03/2008 China, et al.

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2 From 06/2005 To 09/2005 Columbia

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20c.4.0.1
Do you have additional travel outside the U.S. in the last seven (7) years for other than
solely U.S. Government business?
□ Yes
□ No
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Sections 20c: Countries Visited

Section 21 SF86 “Psychological and Emotional Health”
Section 21.0.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Mental health counseling in and of itself is not a reason to revoke or deny eligibility for
access to classified information or for a sensitive position, suitability or fitness to obtain
or retain Federal employment, fitness to obtain or retain contract employment, or
eligibility for physical or logical access to federally controlled facilities or information
systems.
In the last seven (7) years, have you consulted with a health care professional regarding
an emotional or mental health condition or were you hospitalized for such a condition?
Answer ‘No’ if the counseling was for any of the following reasons and was not courtordered:
- strictly marital, family, grief not related to violence by you; or
- strictly related to adjustments from service in a military combat environment.
21.0.0.1
□ Yes
□ No
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proceed to Section 22

Section 21: Psychological and Emotional Health

Section 21.1.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
You responded ‘Yes’ to having consulted with a health care professional regarding a
mental or emotional health condition or were hospitalized for such a condition
21.1.0.1
Provide the dates of counseling or treatment.
Date
Month/Year
Est./Pres.
From:

/

To:

/

21.1.0.2
Provide the name of the health care professional.

21.1.0.3
Provide the address of the health care professional.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
21.1.0.4
Provide the telephone number of the health care professional.
(

Check box if International)
Number
Extension

Time
Both

Section 21: Psychological and Emotional Health

21.1.0.5
Provide the name of agency/organization/facility where counseling/treatment was
provided.
□ Same as above.

21.1.0.6
Provide the address of the agency/organization/facility provider.
□ Address is same as above.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
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Section 21: Psychological and Emotional Health

Section 21.2.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
21.2.0.1
Were you EVER admitted as an inpatient to the agency/organization where
counseling/treatment was provided?
□ Yes
□ No
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Section 21: Psychological and Emotional Health

Section 21.3.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
21.3.0.1
You responded ‘Yes’ to having been admitted as an inpatient to the agency/organization
where counseling/treatment was provided, was the admission voluntary or involuntary?
□ Voluntary (Provide explanation)
□ Involuntary (Provide explanation)
Explanation

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Section 21: Psychological and Emotional Health

Section 21.4.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
21.4.0.1
Has a court or administrative agency EVER declared you mentally incompetent?
□ Yes
□ No
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Section 21: Psychological and Emotional Health

Section 21.5.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
You responded ‘Yes’ to having a court or administrative agency EVER declare you
mentally incompetent.
21.5.0.1
Provide the date this occurred.
Month/Year
Est.
Jan(01)

/

21.5.0.2
Provide the name of the court or administrative agency that declared you mentally
incompetent.

21.5.0.3
Provide the address of the court or administrative agency.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
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Section 21: Psychological and Emotional Health

Section 21.6.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
21.6.0.1
Was this matter appealed to a higher court?
□ Yes
□ No
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Section 21: Psychological and Emotional Health

Section 21.7.0.0 – Psychological and Emotional Health
Section 21: Psychological and Emotional Health
Detail
21.7.0.1
Provide the name of the court.

21.7.0.2
Provide the address of court.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
21.7.0.3
Provide the final disposition.

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Section 21: Psychological and Emotional Health

Section 21.1.8.0 – Psychological and Emotional Health, Summary Screen
Section 21: Psychological and Emotional Health
Summary
Summary of Treatments
# Dates of treatment and/or counseling Name of provider
1 From 01/2004 To 03/2004

Dr. John Doe

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21.8.0.1
In the last seven (7) years, have you consulted with another health care professional
regarding an emotional or mental health condition or were you hospitalized for another
such condition? Answer ‘No’ if the counseling was for any of the following reasons and
was not court-ordered:
- strictly marital, family, grief not related to violence by you; or
- strictly related to adjustments from service in a military combat environment.
□ Yes
□ No
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Section 21: Psychological and Emotional Health

Section 22.0.0.0 – Police Record (Instructions)

Section 22 SF86 “Police Record”
Section 22: Police Record
For this section 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.
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Section 22.1.0.0 – Police Record (Last 7 years questions)
Section 22: Police Record
Police Record
22.1.0.1
Have any of the following happened?

Yes □ No □

(If yes, check all that apply, you will be asked to provide details for each offense that
pertains to the actions you identify below.)
□ In the past seven (7) years have you been issued a summons, citation, or ticket to
appear in court in a criminal proceeding against you? (Do not check if all the citations
involved traffic infractions where the fine was less than $300 and did not include alcohol
or drugs.)
□ In the past seven (7) years have you been arrested by any police officer, sheriff,
marshal or any other type of law enforcement official?
□ In the past seven (7) years have you been charged, convicted, or sentenced of a crime
in any court? (Include all qualifying charges, convictions or sentences in any Federal,
state, local, military, or non-U.S. court, even if previously listed on this form).
□ In the past seven (7) years have you been or are you currently on probation or parole?
□ Are you currently on trial or awaiting a trial on criminal charges?

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Section 22.1.0.0 – Police Record (Last 7 years Summary)
Section 22: Police Record
Police Record Summary
Summary of Offenses
# Date Offense Actions
1 01/2003 DUI

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22.1.0.2
Do you have any other offenses where any of the following has happened to you? □ Yes □ No
•
•
•
•
•

In the past seven (7) years have you been issued a summons, citation, or ticket to appear
in court in a criminal proceeding against you? (Do not include citations involving traffic
infractions where the fine was less than $300 and did not include alcohol or drugs)
In the past seven (7) years have you been arrested by any police officer, sheriff, marshal
or any other type of law enforcement official?
In the past seven (7) years have you been charged, convicted, or sentenced of a crime in
any court? (Include all qualifying charges, convictions, or sentences in a Federal, state,
local, military, or non-U.S. court even if previously listed on this form.)
In the past seven (7) years have you been or are you currently on probation or parole?
Are you currently on trial or awaiting a trial on criminal charges?

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Section 22.2.0.0 – Police Record
Section 22: Police Record
Detailed Entry (Offense Location/Description)
22.2.0.1
Provide the date of offense.
Month/Year

Est.

/
22.2.0.2
Provide a description of the specific nature of the offense.

22.2.0.3
Did this offense involve any of the following? (Check all that apply)
Yes □ No □
□ Domestic violence or a crime of violence (such as battery or assault) against your
child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a
child in common?
□ Involve firearms or explosives?
□ Involve alcohol or drugs?
22.2.0.4
Provide the location where the offense occurred.
City:

County:

Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip:

Country:
22.2.0.5
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this
offense by any police officer, sheriff, marshal or any other type of law enforcement official?
Yes □ No □
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proceed to 22.3.0.0 (Arresting/Citing Agency), if No Proceed to 22.4.0.0 (Charged
Question).

Section 22.3.0.0 – Police Record Arrested
Section 22: Police Record
Detailed Entry (Arresting/Citing Agency)
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency.
City:

County:

Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip:

Country:
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Section 22.4.0.0 – Police Record
Section 22: Police Record
Detailed Entry
22.4.0.1
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered
to appear in court in a criminal proceeding against you?
□ Yes
□ No
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Section 22.4.1.0 – Police Record (Charges)
Section 22: Police Record
Police Record Detail
You responded ‘No’ to “As a result of this offense were you charged, convicted, currently
awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?”
22.4.1.1
Provide explanation.

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Section 22.5.0.0 – Police Record
Section 22: Police Record
Detailed Entry (Court information)
22.5.0.1
Provide the name of the court.

22.5.0.2
Provide the location of the court.
City:

County:

Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip:

Country:
22.5.0.3
Provide all the charges brought against you for this offense, and the outcome of each charged
offense (such as found guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were
found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and
the lesser offense.
Felony /
#
Charge
Outcome
Date Month/Year
Actions
Misdemeanor
1.

/

Delete

2.

/

Delete

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Felony
Misdemeanor
Other
22.5.0.4
Were you sentenced as a result of this offense?
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Yes □ No □

Electronic Form Navigation Note – If yes to 22.5.0.4 (convicted/sentenced), proceed to
22.6.0.0 (Conviction Details), if No Proceed to 22.7.0.0 (Awaiting Trial).

Section 22.6.0.0 – Police Record
Section 22: Police Record
Conviction Detail
22.6.0.1
Provide a description of the sentence.

22.6.0.2
Were you sentenced to imprisonment for a term exceeding 1 year?
□ Yes □ No
22.6.0.3
Were you incarcerated as a result of that sentence for not less than 1 year?
□ Yes □ No
22.6.0.4
If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated.
(Not Applicable □ )
Date
Month/Year
Est./Pres.
From:

/

To:

/

22.6.0.5
If conviction resulted in probation or parole, provide the dates of probation or parole.
(Not Applicable □ )
Date
Month/Year
Est./Pres.
From:

/

To:

/

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Section 22.7.0.0 – Police Record
Section 22: Police Record
Detailed Entry (Court information Cont)
22.7.0.1
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this
offense?
Yes □
No □
Provide Explanation

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Section 22.8.0.0 – Police Record (EVER)
Section 22: Police Record
22.8.0.1
Other than those offenses already listed, have you EVER had the following happen to you?
Yes □ No □
(Check all that apply)
□ Have you EVER been convicted in any court of the United States of a crime, sentenced
to imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of
that sentence for not less than 1 year? (Include all qualifying convictions in Federal, state,
local, or military court, even if previously listed on this form.)
□ Have you EVER been charged with any felony offense? (Include those under the
Uniform Code of Military Justice and non-military/civilian felony offenses.)
□ Have you EVER been convicted of an offense involving domestic violence or a crime
of violence (such as battery or assault) against your child, dependent, cohabitant, spouse,
former spouse, or someone with whom you share a child in common?
□ Have you EVER been charged with an offense involving firearms or explosives?
□ Have you EVER been charged with an offense involving alcohol or drugs?
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Section 22.8.0.0 – Police Record (Ever Summary)
Section 22: Police Record
Police Record Summary
Summary of Offenses
# Date Offense Actions
1 01/2003 Robbery

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22.8.0.2
Do you have any other offenses to list where the following has EVER happened to you?
□ Yes □ No
□ Have you EVER been convicted in any court of the United States of a crime, sentenced
to imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of
that sentence for not less than 1 year? (Include all qualifying convictions in Federal,
state, local, or military court, even if previously listed on this form)
□ Have you EVER been charged with any felony offense? (Include those under the
Uniform Code of Military Justice and non-military/civilian offenses).
□ Have you EVER been convicted of an offense involving domestic violence or a crime
of violence (such as battery or assault) against your child, dependent, cohabitant, spouse,
former spouse, or someone with whom you share a child in common?
□ Have you EVER been charged with an offense involving firearms or explosives?
□ Have you EVER been charged with an offense involving alcohol or drugs?

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Section 22.8.1.0 – Police Record (EVER)
Section 22: Police Record
Detailed Entry (Court information)
22.8.1.1
Provide the date of the conviction or charge.
Month/Year
Est.
/
22.8.1.2
Provide a description of the specific nature of the offense.

22.8.1.3
Did this offense involve any of the following? (Check all that apply)
Yes □ No □
□ Domestic violence or a crime of violence (such as battery or assault) against your
child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a
child in common?
□ Involve firearms or explosives?
□ Involve alcohol or drugs?
22.8.1.4
Provide the name of the court.

22.8.1.5
Provide the location of the court.
City:

County:

Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip:

Country:
22.8.1.6
Provide all the charges brought against you for this offense, and the outcome of each charged
offense (such as found guilty, found not-guilty, or charge dropped or “nolle pros,”, etc). If you
were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the
lesser offense separately.

#

Felony /
Misdemeanor

Charge

Outcome

Date Month/Year

Actions

1.

/

Delete

2.

/

Delete

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Felony
Misdemeanor
Other
22.8.1.6
Were you sentenced as a result of these charges?

Yes □ No □

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22.8.3.0 (awaiting trial or provide explanation)

Section 22.8.2.0 – Police Record (EVER)
Section 22: Police Record
Conviction and Imprisonment Detail (EVER)
22.8.2.1
Provide a description of the sentence.

22.8.2.2
Were you sentenced to imprisonment for a term exceeding 1 year?
□ Yes □ No
22.8.2.3
Were you incarcerated as a result of that sentence for not less than 1 year?
□ Yes □ No
22.8.2.4
If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated.
(Not Applicable □ )
Date
Month/Year
Est./Pres.
From:

/

To:

/

22.8.2.5
If the conviction resulted in probation or parole, provide the dates of probation or parole.
(Not Applicable □)
Date
Month/Year
Est./Pres.
From:

/

To:

/

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Questions.

Section 22.8.3.0 – Police Record
Section 22: Police Record
Detailed Entry (Court information Cont)
22.8.3.1
Are you currently on trail or awaiting a trial, or awaiting sentencing on criminal charges for this
offense?
Yes □
No □
Provide Explanation:

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Section 22.9.0.0 – Police Record Domestic Violence Protective Order
Section 22: Police Record
Domestic Violence Protective Order
22.9.0.1
Is there currently a domestic violence protective order or restraining order issued against you?
□ Yes
□ No
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Section 22.9.1.0 – Police Record Domestic Violence Protective Order
Section 22: Police Record
Domestic Violence Protective Order Detail
You responded ‘Yes’ to currently having a domestic violence protective order or restraining
order issued against you.
22.9.1.1
Provide explanation:

22.9.1.2
Provide the date the order was issued.
Month/Year
Est.
/
22.9.1.3
Provide the name of the court or agency that issued the order.

22.9.1.4
Provide the location of the court or agency that issued the order.
City:

County:

Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip:

Country:
Add Optional Comment

Save

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Domestic violence.

Section 22.9.0.0 – Police Record Domestic Violence Protective Order (Summary)
Section 22: Police Record
Domestic Violence Protective Order Summary
Summary of domestic violence protective orders.
#
Description
Actions
1 Protective Order A

Edit

Delete

22.9.0.2
Do you have another domestic violence protective order or restraining order currently issued
against you to report?
□ Yes
□ No
Add Optional Comment

Save

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to Section 23

Section 23 SF86 “Illegal Use of Drugs and Drug Activity”
Section 23.0.0.0: Illegal Use of Drugs or Drug Activity Instructions
Section 23: Illegal Use of Drugs or Drug Activity
We note, with reference to this section, that neither your truthful responses nor
information derived from your responses to this section will be used as evidence against
you in a subsequent criminal proceeding. As to this particular section, this applies
whether or not you are currently employed by the Federal government.
The following questions pertain to the illegal use of drugs or controlled substances or
drug or controlled substance activity.
Continue

Electronic Form Navigation Note – At “Continue” proceed to Section 23.1.0.0

Sections 23: Drug Activity

Section 23.1.0.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use of Drugs or Controlled Substances
23.1.0.1
In the last seven (7) years, have you illegally used any drugs or controlled substances?
Use of a drug or controlled substance includes injecting, snorting, inhaling, swallowing,
experimenting with or otherwise consuming any drug or controlled substance.
□ Yes
□ No
Add Optional Comment

Save

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Electronic Form Navigation Note – If “Yes” proceed to Section 23.1.1.0, if “No”
proceed to Section 23.2.0.0

Sections 23: Drug Activity

Section 23.1.1.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use of Drugs or Controlled Substances Detail
You answered ‘Yes’ to in the last seven (7) years having illegally used a drug or
controlled substance.
23.1.1.1
Provide the type of drug or controlled substance.

Electronic Form Navigation Note – Drop-down to contain the following:
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Explanation

23.1.1.2
Provide an estimate of the month and year of first use.
Month/Year
Est.
/
23.1.1.3
Provide an estimate of the month and year of most recent use.
Month/Year
Est.
/

Sections 23: Drug Activity

23.1.1.4
Provide nature of use, frequency, and number of times used.

23.1.1.5
Was your use while you were employed as a law enforcement officer, prosecutor, or
courtroom official, or while in a position directly and immediately affecting the public
safety?
□ Yes
□ No
23.1.1.6
Was your use while possessing a security clearance?
□ Yes
□ No
Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.3.2.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use of Drugs or Controlled Substances – Future Use
23.1.2.1
Do you intend to use this drug or controlled substance in the future?
□ Yes
□ No
Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.1.3.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use of Drugs or Controlled Substances – Future Use Detail
23.1.3.1
Provide explanation of why you intend or do not intend to use this drug or controlled
substance in the future.

Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.1.4.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use of Drugs or Controlled Substances
Summary of Substance Use
#
Dates of use/activity

Type of drug(s) or controlled substance(s)

Actions

1 From 06/2005 To 06/2006 Crack Cocaine

Edit

Delete

2 From 04/2005 To 03/2006 Heroin

Edit

Delete

23.1.4.1
Do you have an additional instance(s) of illegal use of a drug or controlled substance to
enter?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.1.1.0, if “No”
proceed to Section 23.2.0.0.

Sections 23: Drug Activity

Section 23.2.0.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Drug Activity
23.2.0.1
In the last seven (7) years, have you been involved in the illegal purchase, manufacture,
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of any
drug or controlled substance?
□ Yes
□ No
Add Optional Comment

Save

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proceed to Section 23.3.0.0

Sections 23: Drug Activity

Section 23.2.1.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Drug Activity Detail
You answered ‘Yes’ to in the last seven (7) years having been involved in the illegal
purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving,
handling or sale of a drug or controlled substance.
23.2.1.1
Provide the type of drug or controlled substance.

Electronic Form Navigation Note – Drop-down to contain the following:
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Explanation:

23.2.1.2
Provide an estimate for the month and year of first involvement.
Month/Year
Est.
/
23.2.1.3
Provide an estimate for the month and year of most recent involvement.
Month/Year
Est.
/
23.2.1.4
Provide the nature and frequency of activity.

Sections 23: Drug Activity

23.2.1.5
Provide the reason(s) why you engaged in the activity.

23.2.1.6
Was your involvement while you were employed as a law enforcement officer,
prosecutor, or courtroom official, or while in a position directly and immediately
affecting the public safety?
□ Yes
□ No
23.2.1.7
Was your involvement while possessing a security clearance?
□ Yes
□ No

Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.2.2.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Drug Activity Future Activity
23.2.2.1
Do you intend to engage in this activity in the future?
□ Yes
□ No
Add Optional Comment

Save

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proceed to Section 23.2.4.0.

Sections 23: Drug Activity

Section 23.2.3.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Drug Activity Future Activity Detail
23.2.3.1
You have indicated that you plan to engage in the illegal purchase, manufacture,
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of a
drug or controlled substance in the future.
Provide explanation.

Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.2.4.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Drug Activity Summary
Summary of drug and controlled substance activity
#
Dates of use/activity
Type of drug(s) or controlled substance(s)

Actions

1 From 06/2005 To 06/2006 Speed

Edit

Delete

2 From 04/2005 To 03/2006 Marijuana

Edit

Delete

23.2.4.1
Do you have an additional instance(s) of having been involved in the illegal purchase,
manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling
or sale of a drug or controlled substance to enter?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

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proceed to Section 23.3.0.0

Sections 23: Drug Activity

Section 23.3.0.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use While Possessing a Security Clearance
23.3.0.1
Have you EVER illegally used or otherwise been involved with a drug or controlled
substance while possessing a security clearance other than previously listed?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.3.1.0, if “No”
proceed to Section 23.4.0.0

Sections 23: Drug Activity

Section 23.3.1.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use While Possessing a Security Clearance Detail
You responded ‘Yes’ to having EVER illegally used or otherwise been involved with a
drug or controlled substance while possessing a security clearance, other than previously
listed.
23.3.1.1
Provide a description of your involvement.

23.3.1.2
Provide the dates of involvement/use.
Date
Month/Year
Est./Pres.
From:

/

To:

/

23.3.1.3
Provide an estimate the number of times you used and/or were involved with this drug or
controlled substance while possessing a security clearance.

Add Optional Comment

Save

Reset this Screen

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Sections 23: Drug Activity

Section 23.3.2.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use While Possessing a Security Clearance Summary
Summary of drug or controlled substance use/activity
Type of drug(s) or controlled substance(s)
#
Dates of use/activity

Actions

1 From 06/2005 To 06/2006 LSC

Edit

Delete

2 From 04/2005 To 03/2006 Steroids

Edit

Delete

23.3.2.1
Do you have an additional instance(s) of the illegal use or involvement with a drug or
controlled substance while possessing a security clearance to enter?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.3.1.0, if “No”
proceed to Section 23.4.0.0

Sections 23: Drug Activity

Section 23.4.0.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use or Possession while Employed as Law Enforcement
23.4.0.1
Have you EVER illegally used or otherwise been involved with a drug or controlled
substance while employed as a law enforcement officer, prosecutor, or courtroom
official; or while in a position directly and immediately affecting the public safety other
than previously listed?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.4.1.0, if “No”
proceed to Section 23.5.0.0

Sections 23: Drug Activity

Section 23.4.0.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use or Possession while Employed as Law Enforcement Detail
You responded ‘Yes’ to having EVER illegally used, or otherwise been involved with a
drug or controlled substance while employed as a law enforcement officer, prosecutor, or
courtroom official; or while in a position directly and immediately affecting the public
safety other than previously listed.
23.4.1.1
Provide a description of the drugs or controlled substances used and your involvement.

23.4.1.2
Provide the dates of involvement/use.
Date
Month/Year
Est./Pres.
From:

/

To:

/

23.4.1.3
Provide an estimate the number of times you used and/or were involved this drug or
controlled substance while employed in this capacity.

Add Optional Comment

Save

Reset this Screen

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Summary

Sections 23: Drug Activity

Section 23.4.2.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Illegal Use or Possession while Employed as Law Enforcement Summary
Summary of substance/drug use/activity
Type of drug(s) or controlled substance(s)
#
Dates of use/activity

Actions

1 From 06/2005 To 06/2006 Ecstasy

Edit

Delete

2 From 04/2005 To 03/2006 PCP

Edit

Delete

23.4.2.1
Do you have an additional instance(s) of illegal use or involvement with a drug or
controlled substance while employed as a law enforcement officer, prosecutor, or
courtroom official; or while in a position directly and immediately affecting the public
safety to enter?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.4.1.0, if “No”
proceed to Section 23.5.0.0

Sections 23: Drug Activity

Section 23.5.0.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Misuse of Prescription Drugs
23.5.0.1
In the last seven (7) years have you intentionally engaged in the misuse of prescription
drugs, regardless of whether or not the drugs were prescribed for you or someone else?
□ Yes
□ No
Add Optional Comment

Save

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proceed to Section 23.6.0.0

Sections 23: Drug Activity

Section 23.5.1.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Misuse of Prescription Drugs Detail
You responded ‘Yes’ to in the last seven (7) years having intentionally engaged in the
misuse of prescription drugs, regardless of whether the drugs were prescribed for you or
someone else.
23.5.1.1
Provide the names of the prescription drug that you misused.

23.5.1.2
Provide the dates of involvement in the above.
Date
Month/Year
Est./Pres.
From:

/

To:

/

23.5.1.3
Provide the reason(s) for and circumstances of the misuse of the prescription drug.

23.5.1.4
Was your involvement while you were employed as a law enforcement officer,
prosecutor, or courtroom official, or while in a position directly and immediately
affecting the public safety?
□ Yes
□ No
23.5.1.5
Was your involvement while possessing a security clearance?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

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Sections 23: Drug Activity

Section 23.5.2.0: Illegal Use of Drugs or Drug Activity
Section 23: Illegal Use of Drugs or Drug Activity
Misuse of Prescription Drugs Summary
Summary of prescription drug use/activity
Type of drug(s) or controlled substance(s)
#
Dates of use/activity

Actions

1 From 06/2005 To 06/2006 Demerol

Edit

Delete

2 From 04/2005 To 03/2006 Rouphenol

Edit

Delete

23.5.2.1
Do you have an additional instance(s) of intentionally engaging in the misuse of
prescription drugs in the last seven (7) years to enter?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.5.1.0, if “No”
proceed to Section 23.6.0.0.

Sections 23: Drug Activity

Section 23.6.0.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs
23.6.0.1
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a
result of your illegal use of drugs or controlled substances?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Screen 23.6.1.0, if “No”
proceed to Screen 23.7.0.0.

Sections 23: Drug Activity

Section 23.6.2.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs – Voluntary Treatment Detail
You responded ‘Yes’ to having EVER been ordered, advised, or asked to seek
counseling or treatment as a result of your illegal use of drugs or controlled substances
23.6.2.1
Have any of the following ordered, advised, or asked you to seek counseling or treatment
as a result of your illegal use of drugs or controlled substances? (Check all that apply)
□ An employer, military commander, or employee assistance program
□ A medical professional
□ A mental health professional
□ A court official / judge
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the
above.
Provide explanation:

Add Optional Comment

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Sections 23: Drug Activity

Section 23.6.3.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs
23.6.3.1
Did you take action to receive counseling or treatment?
□ Yes
□ No
Add Optional Comment

Save

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Electronic Form Navigation Note – If “Yes” proceed to Screen 23.6.5.0, if “No”
proceed to Screen 23.6.4.0.

Sections 23: Drug Activity

Section 23.6.4.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs - Unsuccessful Treatment
23.6.4.1
You have indicated that you did not receive treatment.
Provide explanation.

Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.6.5.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs - Detail
23.6.5.1
Provide the type of drug or controlled substance for which you were treated.

Electronic Form Navigation Note – Drop-down to contain the following:
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Explanation:

23.6.5.2
Provide the name of the treatment provider. (Last name, First name)

23.6.5.3
Provide the address for this treatment provider.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:

Sections 23: Drug Activity

23.6.5.4
Provide a phone number for the treatment provider.
(_ Check box if International)
Number
Extension
Time
Evening

23.6.5.5
Provide the dates of treatment.
Date
Month/Year
From:

/

To:

/

Est./Pres.

Add Optional Comment

Save

Reset this Screen

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Sections 23: Drug Activity

Section 23.6.6.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs – Compliance Treatment Completion
23.6.6.1
Did you successfully complete the treatment?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

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proceed to Screen 23.6.7.0.

Sections 23: Drug Activity

Section 23.6.7.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs - Unsuccessful Treatment
23.6.7.1
You have indicated that you did not you successfully complete the treatment.
Provide explanation.

Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.6.8.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs – Treatment Summary
Summary of having been ordered, advised, or asked to seek counseling or treatment.
#
Reason
Treatment provider Actions
1 Sought Voluntarily ABC Drug Treatment

Edit

Delete

2 Ordered to Seek

Edit

Delete

No Treatment

23.6.8.1
Do you have another instance of having been ordered, advised, or asked to seek drug or
controlled substance counseling or treatment to enter?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.6.2.0, if “No”
proceed to Section 23.7.0.0.

Sections 23: Drug Activity

Section 23.7.0.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs
23.7.0.1
Have you EVER voluntarily sought counseling or treatment as a result of your use of a
drug or controlled substance?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Screen 23.7.1.0, if “No”
proceed to Screen 23.5.0.0.

Sections 23: Drug Activity

Section 23.7.1.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs - Detail
23.7.1.1
Provide the type of drug or controlled substance for which you were treated.

Electronic Form Navigation Note – Drop-down to contain the following:
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Explanation:

23.7.1.2
Provide the name of the treatment provider. (Last Name, First Name)

23.7.1.3
Provide the address for this treatment provider.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:

Sections 23: Drug Activity

23.7.1.4
Provide a phone number for the treatment provider.
(_ Check box if International)
Number
Extension
Time
Evening

23.7.1.5
Provide the dates of treatment.
Date
Month/Year
From:

/

To:

/

Est./Pres.

Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – At “Save” proceed to Section 23.7.2.0.

Sections 23: Drug Activity

Section 23.7.2.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs – Compliance Treatment Completion
23.7.2.1
Did you successfully complete the treatment?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Screen 23.7.4.0, if “No”
proceed to Screen 23.7.3.0.

Sections 23: Drug Activity

Section 23.7.3.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs - Unsuccessful Treatment
23.7.3.1
You have indicated that you did not you successfully complete the treatment.
Provide explanation.

Add Optional Comment

Save

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Sections 23: Drug Activity

Section 23.7.4.0: Treatment for Illegal Use of Drugs or Controlled
Substances
Section 23: Illegal Use of Drugs or Drug Activity
Treatment for the Use of Drugs – Treatment Summary
Summary of seeking counseling or treatment.
#
Reason
Treatment provider

Actions

1 Sought Voluntarily ABC Drug Treatment

Edit

Delete

2 Ordered to Seek

Edit

Delete

No Treatment

23.7.4.1
Do you have another instance of EVER voluntarily seeking counseling or treatment as a
result of your use of a drug or controlled substance?
□ Yes
□ No
Add Optional Comment

Save

Reset this Screen

Electronic Form Navigation Note – If “Yes” proceed to Section 23.7.1.0, if “No”
proceed to Section 24.0.0.0.

Sections 23: Drug Activity

Section 24 SF86 “Use of Alcohol”
Section 24.1.0.0 - Use of Alcohol
Section 24: Use of Alcohol
Negative Impact
In the last seven (7) years has your use of alcohol had a negative impact on your work
performance, your professional or personal relationships, your finances, or resulted in
intervention by law enforcement/public safety personnel?
□ Yes
□ No
Add Optional Comment

Save

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Electronic Form Navigation Note – If “Yes” proceed to Section 24.1.1.0, if “No” proceed
to Section 24.2.0.0.

Sections 24: Use of Alcohol

Section 24.1.1.0 - Use of Alcohol
Section 24: Use of Alcohol
Negative Impact Detail
You responded ‘Yes’ to your alcohol use having 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.
24.1.1.1
Provide the month/year when this negative impact occurred.
Month/Year
Est.
/
24.1.1.2
Provide an explanation of the circumstances and the negative impact.
Provide circumstances:
Provide negative impact:

24.1.1.3
Provide the dates of involvement or use.
Date
Month/Year
Est./Pres.
From:

/

To:

/

Add Optional Comment

Save

Reset this Screen

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Sections 24: Use of Alcohol

Section 24.1.1.0 - Use of Alcohol
Section 24: Use of Alcohol
Negative Impact Summary
# Dates of Negative Impact
1 From 02/2004 To 03/2004

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Has the use of alcohol had other negative impacts on your work performance, your professional
or personal relationships, your finances, or resulted in intervention by law enforcement/public
safety personnel?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.2.0.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of
your use of alcohol?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.2.1.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling Detail
You responded ‘Yes” to having been ordered, advised or asked to seek counseling or treatment
as a result of your use of alcohol.
24.2.1.1
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a
result of your use of alcohol? (Check all that apply)
□ An employer, military commander, or employee assistance program
□ A medical professional
□ A mental health professional
□ A court official / judge
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.
□ Other (Provide Explanation)
24.2.1.2
Explanation:

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Sections 24: Use of Alcohol

Section 24.2.2.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling, Counseling or Treatment Sought
24.2.2.1
Did you take action to seek counseling or treatment?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.2.3.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling, Counseling or Treatment Sought Detail
24.2.3.1
You responded ‘No’ to having taken action to seek counseling or treatment.
Explain the reasons for not taking action to seek counseling or treatment.

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Sections 24: Use of Alcohol

Section 24.2.4.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling – Counseling Detail
You responded ‘Yes’ to having taken action to seek counseling or treatment.
24.2.4.1
Provide the dates of counseling or treatment.
Date
Month/Year
Est./Pres.
From:

/

To:

/

24.2.4.2
Provide the name of the individual counselor or treatment provider.

24.2.4.3
Provide the full address of the counseling/treatment provider.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
24.2.4.4
Provide telephone number.
(

Check box if International)
Number
Extension

Time
Both

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Sections 24: Use of Alcohol

Section 24.2.5.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling, Outcome of Treatment
24.2.5.0
Did you successfully complete the treatment program?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.2.6.0 - Use of Alcohol
Section 24: Use of Alcohol
Ordered to Seek Counseling, Outcome of Treatment Detail
24.2.6.1
You responded “No” to having successfully completed the treatment program.
Provide explanation

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Sections 24: Use of Alcohol

Section 24.2.7.0 - Use of Alcohol
Section 24: Use of Alcohol Summary
Ordered to Seek Counseling, Outcome of Treatment
#

Dates of treatment

Counselor or doctor

1 From 02/2006 To 03/2006 Charles Smith

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24.2.7.1
Do you have additional instances of having been ordered, advised or asked to seek counseling or
treatment as a result of your use of alcohol to enter?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.3.0.0 - Use of Alcohol
Section 24: Use of Alcohol
Sought Counseling or Treatment
Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.3.1.0 - Use of Alcohol
Section 24: Use of Alcohol
Sought Counseling or Treatment – Counseling Detail
You responded ‘Yes’ to voluntarily seeking counseling or treatment.
24.3.1.1
Provide dates of counseling or treatment.
Date
Month/Year
Est./Pres.
From:

/

To:

/

24.3.1.2
Provide the name of the individual counselor or treatment provider.

24.3.1.3
Provide the full address of the counseling/treatment provider.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
24.3.1.4
Provide telephone number.
(

Check box if International)
Number
Extension

Time
Both

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Sections 24: Use of Alcohol

Section 24.3.2.0 - Use of Alcohol
Section 24: Use of Alcohol
Sought Counseling or Treatment, Completion of Treatment
24.3.2.0
Did you successfully complete the treatment program?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.3.3.0 - Use of Alcohol
Section 24: Use of Alcohol
Sought Counseling or Treatment, Completion of Treatment Detail
24.3.3.1
You answered ‘No’ to having successfully completed the treatment program.
Provide explanation:

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Sections 24: Use of Alcohol

Section 24.3.4.0 - Use of Alcohol
Section 24: Use of Alcohol
Sought Counseling or Treatment, Outcome of Treatment Summary
#

Dates of treatment

Counselor or Treatment Provider

1 From 02/2006 To 03/2006 Charles Smith

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24.3.4.1
Do you have additional instances where you have voluntarily sought counseling or treatment as a
result of your use of alcohol to enter?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.4.0.0 - Use of Alcohol
Section 24: Use of Alcohol
EVER Received Counseling/Treatment
Have you EVER received counseling or treatment as a result of your use of alcohol in addition
to what you have already listed on this form?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 24.4.1.0 - Use of Alcohol
Section 24: Use of Alcohol
EVER Received Counseling/Treatment
You responded ‘Yes’ to having EVER received counseling or treatment as a result of your use of
alcohol.
24.4.1.1
Provide the name of individual counselor or treatment provider.

24.4.1.2
Provide the full address of counseling/treatment provider.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
24.4.1.3
Provide the name of agency/organization where counseling/treatment was provided.

24.4.1.4
Provide the address of agency/organization where counseling/treatment was provided:
□ Same as above
Street:
City:

County:

Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
24.4.1.5
Provide the date counseling or treatment began.
Month/Year
Est.
/

Sections 24: Use of Alcohol

24.4.1.6
Provide the date counseling or treatment ended.
Month/Year
Est./Pres
/
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Sections 24: Use of Alcohol

Section 24.4.1.0 - Use of Alcohol
Section 24: Use of Alcohol
EVER Received Counseling/Treatment
24.4.2.1
Did you successfully complete your counseling or treatment?
□ Yes (Provide explanation)
□ No (Provide explanation)
Explanation:

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Sections 24: Use of Alcohol

Section 24.4.3.0 - Use of Alcohol
Section 24: Use of Alcohol
EVER Received Counseling/Treatment Summary
#

Dates of treatment

Counselor or Treatment Provider

1 From 02/2004 To 03/2004 Dr. Laura

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24.4.3.1
Did you receive alcohol-related counseling or treatment another time?
□ Yes
□ No
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Sections 24: Use of Alcohol

Section 25 SF86 “Investigations and Clearance Record”
Section 25.1.0.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Investigation History
25.1.0.1
Has the U.S. Government (or a foreign government) EVER investigated your background and/or
granted you a security clearance eligibility/access?
□ Yes
□ No
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Sections 25: Investigations and Clearance Record

Section 25.1.1.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Investigation History Detail
You responded ‘Yes’ to the U.S. Government (or a foreign government) having investigated
your background and/or having granted you a security clearance eligibility/access
25.1.1.1
Provide the investigating agency:
□ U.S. Department of Defense
□ U.S. Department of State
□ U.S. Office of Personnel Management
□ Federal Bureau of Investigation
□ U.S. Department of Treasury
□ U.S. Department of Homeland Security
□ Foreign government, (Provide name of government)
□ I don’t know
□ Other (Provide explanation)
Explanation or name of government

25.1.1.2
Date the investigation was completed.
□ I don’t know
Month/Year
Est.
/
25.1.1.3
Provide the name of agency that issued the clearance eligibility/access if different from the
investigating agency.

25.1.1.4
Provide the date clearance eligibility/access was granted.
□ I don’t know
Month/Year
Est.
/
25.1.1.5
Provide the level of clearance eligibility/access granted.
□ None

Sections 25: Investigations and Clearance Record

□ Confidential
□ Secret
□ Top Secret
□ Sensitive Compartmented Information (SCI)
□Q
□L
□ I don’t know
□ Issued by foreign country
□ Other (Provide explanation)
Explanation:

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Sections 25: Investigations and Clearance Record

Section 25.1.2.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Investigation History Summary
Summary of your investigations
# Month/Year Agency code

Other agency Clearance code

Actions

1 04/2005

State Department (~)

Top Secret

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2 03/1999

Other (Explain)

I don’t know

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Canada

25.1.2.1
Do you have another investigation to enter?
□ Yes
□ No
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Sections 25: Investigations and Clearance Record

Section 25.2.0.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Denied Clearance
25.2.0.1
Have you EVER had a security clearance eligibility/access authorization denied, suspended, or
revoked? (Note: An administrative downgrade or administrative termination of a security
clearance is not a revocation.)
□ Yes
□ No
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Sections 25: Investigations and Clearance Record

Section 25.2.1.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Denied Clearance Detail
You responded ‘Yes’ to having ever had a security clearance eligibility/access authorization
denied, suspended, or revoked.
25.2.1.1
Provide the date security clearance eligibility/access authorization was denied, suspended or
revoked.
Month/Year
Est.
/
25.2.1.2
Provide the name of the agency that took the action.

25.2.1.3
Provide an explanation of the circumstances of the denial, suspension or revocation action.

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Sections 25: Investigations and Clearance Record

Section 25.2.2.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Denied Clearance Summary
Summary of your security clearance eligibility/access actions.
# Month/Year Department or agency taking action Actions
1 03/2001

DOD

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25.2.2.0
Do you have another denied, revoked or suspended security clearance eligibility/access
authorization to enter?
□ Yes
□ No
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Sections 25: Investigations and Clearance Record

Section 25.3.0.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Government Debarment
Have you EVER been debarred from government employment?
□ Yes
□ No
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Sections 25: Investigations and Clearance Record

Section 25.3.1.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Government Debarment Detail
You responded ‘Yes’ to having EVER been debarred from government employment.
25.3.1.1
Provide the name of the government agency taking debarment action.

Electronic Form Navigation Note – Dropdown list of all U.S. Government agencies.
25.3.1.2
Provide the date the debarment occurred.
Month/Year
Est.
/
25.3.1.3
Provide an explanation of the circumstances of the debarment.

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Sections 25: Investigations and Clearance Record

Section 25.3.2.0 - Investigations and Clearance Record
Section 25: Investigations and Clearance Record
Government Debarment Summary
Summary of Your Debarments
# Month/Year Department or agency taking action
1 11/2006

Treasury Department

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25.3.2.1
Do you have another Government debarment to enter?
□ Yes
□ No
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Sections 25: Investigations and Clearance Record

Section 26: Financial Record
Section 26.1.0.0 – Financial Record
Section 26: Financial Record
Bankruptcy
26.1.0.1
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy
code?
□ Yes
□ No
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Section 26: Financial Record

Section 26.1.1.0 – Financial Record
Section 26: Financial Record
Bankruptcy Detail
You responded ‘Yes’ to having filed a petition under any chapter of the bankruptcy code.
26.1.1.1
Select the applicable bankruptcy petition type:

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Contents of drop-down:
□ Chapter 7
□ Chapter 11
□ Chapter 13
26.1.1.2
Provide the bankruptcy court docket/account number.

26.1.1.3
Provide the date bankruptcy was filed.
Month/Year
Est.
/

□

26.1.1.4
Provide date of bankruptcy discharge.
□ Not Applicable
Month/Year
Est.
/

□

26.1.1.5
Provide the total amount (in U.S. dollars) involved in the bankruptcy.
□ Estimated

26.1.1.6
Provide the name debt is recorded under.
Last name:

Section 26: Financial Record

First name:
Middle name:

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provided the following two questions (26.1.1.6 and 26.1.1.7) will be replaced with
a single drop-down of possible courts.
26.1.1.7
Provide the name of the court involved.

26.1.1.8
Provide the address of the court involved.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
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Section 26: Financial Record

Section 26.1.2.0 – Financial Record
Section 26: Financial Record
Bankruptcy Detail – Chapter 13
26.1.2.1
Provide the name of the trustee for this bankruptcy.

26.1.2.2
Provide the address of the trustee for this bankruptcy.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
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Section 26: Financial Record

Section 26.1.3.0 – Financial Record
Section 26: Financial Record
Bankruptcy Detail Continued
26.1.3.1
Were you discharged of all debts claimed in the bankruptcy?
□ Yes
□ No
26.1.3.2
Provide explanation.

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Section 26: Financial Record

Section 26.1.4.0 – Financial Record
Section 26: Financial Record
Bankruptcy Summary
Summary of bankruptcies
# Date of bankruptcy Court location
1 05/2005

Miami, FL

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26.1.4.1
In the last seven (7) years, have you filed any additional petitions under any chapter of
the bankruptcy code?
□ Yes
□ No
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Section 26: Financial Record

Section 26.2.0.0 – Financial Record
Section 26: Financial Record
Financial Problems Due to Gambling
26.2.0.1
Have you EVER experienced financial problems due to gambling?
□ Yes
□ No
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Section 26: Financial Record

Section 26.2.1.0 – Financial Record
Section 26: Financial Record
Financial Problems Due to Gambling Details
You responded ‘Yes’ to having EVER experienced financial problems due to gambling.
26.2.1.1
Provide the date range of your financial problems due to gambling.
Date
Month/Year
Est./Pres
From:

/

To:

/

26.2.1.2
Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.

26.2.1.3
Provide a description of your financial problems due to gambling.

26.2.1.4
If you have taken any action(s) to rectify your financial problems due to gambling,
provide a description of your actions. If you have not taken any action(s) provide
explanation.

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Section 26: Financial Record

Section 26.2.2.0 – Financial Record
Section 26: Financial Record
Financial Problems Due to Gambling Summary
Summary of financial problems due to gambling:
Dates of Problem
Actions
# Amount of Losses
1 $90,0000

12/02/2003 – 12/12/2004

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26.2.2.1
Have you EVER experienced additional financial problems due to gambling?
□ Yes
□ No
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Section 26: Financial Record

Section 26.3.0.0 – Financial Record
Section 26: Financial Record
Failed to Pay/File Taxes
26.3.0.1
In the past seven (7) years have you failed to file or pay Federal, state, or other taxes
when required by law or ordinance?
□ Yes
□ No
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Section 26: Financial Record

Section 26.3.1.0 – Financial Record
Section 26: Financial Record
Failed to File/Pay Taxes Detail
You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when
required by law or ordinance.
26.3.1.1
Did you fail to file, pay as required, or both?
□ File
□ Pay
□ Both
26.3.1.2
Provide the year you failed to file or pay your Federal, state or other taxes.

26.3.1.3
Provide the reason(s) for your failure to file or pay required taxes.

26.3.1.4
Provide the Federal, state or other agency to which you failed to file or pay taxes.

26.3.1.5
Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.).

26.3.1.6
Provide the amount (in U.S. dollars) of the taxes.
□ Estimated

26.3.1.7
Provide date satisfied.
□ Not applicable
Month/Year
/

Est.
□

26.3.1.8

Section 26: Financial Record

Provide a description of any action(s) you have taken to satisfy this debt (such as
withholdings, frequency and amount of payments, etc.). If you have not taken any
action(s) provide explanation.

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Section 26: Financial Record

Section 26.3.2.0 – Financial Record
Section 26: Financial Record
Failed to File or Pay Taxes Summary
Summary of failure to file or pay taxes:
# Year(s) Taxes Not Paid Agency Actions
1 05/2005

IRS

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26.3.2.1
Are there any other instances in the past seven (7) years where you failed to file or pay
Federal, state or other taxes when required by law or ordinance?
□ Yes
□ No
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Section 26: Financial Record

Section 26.4.0.0 – Financial Record
Section 26: Financial Record
Employer Travel or Credit Card – Violation of Terms
26.4.0.1
In the past seven (7) years have you been counseled, warned, or disciplined for violating
the terms of agreement for a travel or credit card provided by your employer?
□ Yes
□ No
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Section 26: Financial Record

Section 26.4.1.0 – Financial Record
Section 26: Financial Record
Employer Travel or Credit Card – Violation of Terms Detail
You responded ‘Yes’ to having been counseled, warned, or disciplined for violating the
terms of agreement for a travel or credit card provided by your employer.
26.4.1.1
Provide the name of the agency or company.

26.4.1.2
Provide the address of the agency or company.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
26.4.1.3
Provide the date of your counseling, warning, or disciplinary action.
Month/Year
Est.
/

□

26.4.1.4
Provide the reason(s) for the counseling, warning or disciplinary action.

26.4.1.5
Provide the amount (in U.S. dollars) of violation.
□ Estimated

26.4.1.6
Provide a description of any action(s) you have taken to rectify this situation. If you have
not taken any action(s) provide explanation.

Add Optional Comment

Section 26: Financial Record

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Section 26: Financial Record

Section 26.4.2.0 – Financial Record
Section 26: Financial Record
Employer Travel or Credit Card – Violation of Terms Summary
Summary of employer travel or credit card violations:
# Date of Violation Name of Employer Actions
1 02/21/1995

General Motors

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26.4.2.1
Are there any other instances in the past seven (7) years where you have been counseled,
warned, or disciplined for violating the terms of agreement for a travel or credit card
provided by your employer?
□ Yes
□ No
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Section 26: Financial Record

Section 26.5.0.0 – Financial Record
Section 26: Financial Record
Involved or Seeking Assistance for Financial Difficulties
26.5.0.1
Are you currently utilizing, or seeking assistance from, a credit counseling service or
other similar resource to resolve your financial difficulties?
□ Yes
□ No
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Section 26: Financial Record

Section 26.5.1.0 – Financial Record
Section 26: Financial Record
Involved or Seeking Assistance for Financial Difficulties Detail
You responded ‘Yes’ to currently utilizing, or seeking assistance from, a credit
counseling service or other similar resource to resolve your financial difficulties.
26.5.1.1
Provide explanation:

26.5.1.2
Provide the name of the credit counseling organization or resource.

26.5.1.3
Provide the phone number of the credit counseling organization.
(

Check box if International)
Number
Extension

Time
Both

26.5.1.4
Provide the location of the credit counseling organization.
City
State
26.5.1.5
As a result of this counseling, provide a description of any action(s) you have taken to
resolve your financial difficulties. If you have not taken any action(s) provide
explanation.

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Section 26: Financial Record

Section 26.5.2.0 – Financial Record
Section 26: Financial Record
Involved or Seeking Assistance for Financial Difficulties Summary
Summary of financial assistance:
Name of Service
Actions
#
1 Credit One Counseling

Edit

Delete

26.5.2.1
Are you currently utilizing, or seeking assistance from any other credit counseling service
or other similar resource to resolve your financial difficulties?
□ Yes
□ No
Add Optional Comment

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proceed to Section 26.6.0.0

Section 26: Financial Record

Section 26.6.0.0 – Financial Record
Section 26: Financial Record
Financial Issues - Delinquency Involving Enforcement
26.6.0.1
Other than previously listed, have any of the following happened to you? (You will be
asked to provide details about each financial obligation that pertains to the items
identified below).
□ Yes
□ No
•
•
•
•

In the past seven (7) years, you have been delinquent on alimony or child support
payments.
In the past seven (7) years, you had a judgment entered against you. (Include
financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
In the past seven (7) years, you had a lien placed against your property for failing
to pay taxes or other debts. (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations
for which you are the sole debtor, as well as those for which you are a cosigner or
guarantor).

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Section 26: Financial Record

Section 26.6.1.0 – Financial Record
Section 26: Financial Record
Financial Issues Detail – Delinquency Involving Enforcement Detail
You answered ‘Yes’ to having experienced one or more of the previously stated financial
issues.
26.6.1.1
Provide the name of agency/organization/individual to which debt is/was owed

26.6.1.2
Did/does this financial issue include any of the following: (Check all that apply)
□ Yes
□ No
□ In the past seven (7) years , you have been delinquent on alimony or child
support payments.
□ In the past seven (7) years, you had a judgment entered against you. (Include
financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
□ In the past seven (7) years, you had a lien placed against your property for
failing to pay taxes or other debts. (Include financial obligations for which you
were the sole debtor, as well as those for which you were a cosigner or guarantor).
□ You are currently delinquent on any Federal debt. (Include financial
obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).
26.6.1.3
Provide the associated loan / account number(s) involved

26.6.1.4
Identify/describe the type of property involved (if any).

26.6.1.5
Provide the amount (in U.S. dollars) of the financial issue.
□ Estimated

Section 26: Financial Record

26.6.1.6
Provide the reason(s) for the financial issue.

26.6.1.7
Provide the current status of the financial issue.

26.6.1.8
Provide the date the financial issue began.
Month/Year
Est.
/

□

26.6.1.9
Provide date the financial issue was resolved.
□ Not resolved
Month/Year
Est.
/

□

26.6.1.10
Provide the name of the court involved.

26.6.1.11
Provide the address of the court involved.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
26.6.1.12
Provide a description of any action(s) you have taken to satisfy this debt (such as
withholdings, frequency and amount of payments, etc.). If you have not taken any
action(s) provide explanation.

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Section 26: Financial Record

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Section 26: Financial Record

Section 26.6.2.0 – Financial Record
Section 26: Financial Record
Financial Issues - Delinquency Involving Enforcement Summary
Summary of financial issues:
# Date of Issue Agency/Institution/Individual Owed Amount

Actions

1 02/2007

Jane Doe (my ex wife)

$2,500

Edit

Delete

2 11/2008

U.S. Department of Education

$4,500

Edit

Delete

3 05/2005

GMAC

$12,000

Edit

Delete

26.6.2.1
Other than previously listed, are there any other instances of the following occurrences?
□ Yes
□ No
•
•
•
•

In the past seven (7) years, you have been delinquent on alimony or child support
payments.
In the past seven (7) years, you had a judgment entered against you. (Include
financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
In the past seven (7) years, you had a lien placed against your property for failing
to pay taxes or other debts. (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations
for which you are the sole debtor, as well as those for which you are a cosigner or
guarantor).

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Section 26: Financial Record

Section 26.7.0.0 – Financial Record
Section 26: Financial Record
Financial Issues - Delinquency Involving Routine Accounts
26.7.0.1
Other than previously listed, have any of the following happened?
□ Yes
□ No
•

•
•
•

•
•
•
•

In the past seven (7) years, you had any possessions or property voluntarily or
involuntarily repossessed or foreclosed? (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or
guarantor)
In the past seven (7) years, you defaulted on any type of loan? (Include financial
obligations for which you were the sole debtor, as well as those for which you
were a cosigner or guarantor)
In the past seven (7) years, you had bills or debts turned over to a collection
agency? (Include financial obligations for which you were the sole debtor, as
well as those for which you were a cosigner or guarantor)
In the past seven (7) years, you had any account or credit card suspended,
charged off, or cancelled for failing to pay as agreed? (Include financial
obligations for which you were the sole debtor, as well as those for which you
were a cosigner or guarantor)
In the past seven (7) years, you were evicted for non-payment?
In the past seven (7) years, you had your wages, benefits, or assets garnished or
attached for any reason?
In the past seven (7) years, you have been over 120 days delinquent on any debt
not previously entered? (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor)
You are currently over 120 days delinquent on any debt? (Include financial
obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor)

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Section 26: Financial Record

Section 26.7.1.0 – Financial Record
Section 26: Financial Record
Financial Issues – Delinquency Involving Routine Accounts Detail
You answered ‘Yes’ to having experienced one or more of the previously stated financial
issues.
26.7.1.1
Provide the name of agency/organization/individual to which debt is/was owed.
26.7.1.2
Did/does this financial issue include any of the following: (Check all that apply)
□ Yes □ No
□ In the past seven (7) years you had your possessions or property voluntarily or
involuntarily repossessed or foreclosed. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or
guarantor).
□ In the past seven (7) years you defaulted on any type of loan. (Include
financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
□ In the past seven (7) years you had bills or debts turned over to a collection
agency. (Include financial obligations for which you were the sole debtor, as well
as those for which you were a cosigner or guarantor).
□ In the past seven (7) years you had an account or credit card suspended,
charged off, or cancelled for failing to pay as agreed. (Include financial
obligations for which you were the sole debtor, as well as those for which you
were a cosigner or guarantor).
□ In the past seven (7) years you were evicted for non-payment.
□ In the past seven (7) years you had wages, benefits, or assets garnished or
attached for any reason.
□ In the past seven (7) years you were over 120 days delinquent on any debt not
previously entered. (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor).
□ You are currently over 120 days delinquent on any debt. (Include financial
obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).

Section 26: Financial Record

26.7.1.3
Provide the associated loan / account number(s) involved.

26.7.1.4
Identify/describe the type of property involved (if any).

26.7.1.5
Provide the amount (in U.S. dollars) of the financial issue.
□ Estimated

26.7.1.6
Provide the reason(s) for the financial issue.

26.7.1.7
Provide the current status of the financial issue.

26.7.1.8
Provide the date the financial issue began.
Month/Year
Est.
/

□

26.7.1.9
Provide date the financial issue was resolved.
□ Not resolved
Month/Year
Est.
/

□

26.7.1.10
Provide a description of any action(s) you have taken to satisfy this debt (such as
withholdings, frequency and amount of payments, etc.). If you have not taken any
action(s) provide explanation.

Add Optional Comment

Section 26: Financial Record

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Section 26: Financial Record

Section 26.7.2.0 – Financial Record
Section 26: Financial Record
Financial Issues - Delinquency Involving Routine Accounts Summary
Summary of financial issues:
# Date of Issue Agency/Institution/Individual Owed Amount

Actions

1 02/2006

Shady Acres Apartments

$7,500

Edit

Delete

2 11/2004

MBNA

$2,000

Edit

Delete

3 05/2009

Adelphia Cable Company

$125

Edit

Delete

26.7.2.1
Other than previously listed, you are there any other instances of the following
occurrences?
□ Yes
□ No
•

•
•
•

•
•
•
•

In the past seven (7) years, you had any possessions or property voluntarily or
involuntarily repossessed or foreclosed. (include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or
guarantor).
In the past seven (7) years, you defaulted on any type of loan, (Include financial
obligations for which you were the sole debtor, as well as those for which you
were a cosigner or guarantor).
In the past seven (7) years, you had bills or debts turned over to a collection
agency. (Include financial obligations for which you were the sole debtor, as well
as those for which you were a cosigner or guarantor).
In the past seven (7) years, you had any account or credit card suspended,
charged off, or cancelled for failing to pay as agreed. (Include financial
obligations for which you were the sole debtor, as well as those for which you
were a cosigner or guarantor).
In the past seven (7) years, you have been evicted for non-payment.
In the past seven (7) years, you had your wages, benefits, or assets garnished or
attached for any reason.
In the past seven (7) years, you have been over 120 days delinquent on any debt
not previously entered. (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor).
You are currently over 120 days delinquent on any debt. (Include financial
obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).

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Section 26: Financial Record

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Section 26: Financial Record

Section 27 SF86 “Use of Information Technology Systems”
Section 27.0.0.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Instructions
We note, with reference to this section, that neither your truthful responses nor information
derived from your responses to this section will be used as evidence against you in a subsequent
criminal proceeding. As to this particular section, this applies whether or not you are currently
employed by the Federal government.
The following questions ask about your use of information technology systems. Information
technology systems include all related computer hardware, software, firmware, and data used for
the communication, transmission, processing, manipulation, storage or protection of information.
Continue

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Section 27: Use of IT Systems

Section 27.1.0.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Unauthorized Access
27.1.0.1
In the last seven (7) years have you illegally or without proper authorization accessed or
attempted to access any information technology system?
□ Yes
□ No
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Section 27: Use of IT Systems

Section 27.1.1.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Unauthorized Access Details
You responded ‘Yes’ to having in the last seven (7) years illegally or without proper
authorization entered or attempted to enter into any information technology system.
27.1.1.1
Provide the date of the incident
Month/Year

Est.

/
27.1.1.2
Provide a description of the nature of the incident or offense.

27.1.1.3
Provide the location where the incident took place.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
27.1.1.4
Provide a description of the action (administrative, criminal or other) taken as a result of this
incident.

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Section 27: Use of IT Systems

Section 27.1.2.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Unauthorized Access Summary
Summary of Incidents
# Date of incident Location
1 05/2005

Miami, FL

Actions
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27.1.2.0
Are there any other incidents to report?
□ Yes
□ No
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Section 27: Use of IT Systems

Section 27.2.0.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Modified/Destroyed/Manipulated/Denied Access to Information System
27.2.0.1
In the last seven (7) years have you illegally or without authorization, modified, destroyed,
manipulated, or denied others access to information residing on an information technology
system or attempted any of the above?
□ Yes
□ No
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Section 27: Use of IT Systems

Section 27.2.1.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Modified/Destroyed/Manipulated/Denied Access to Information System Detail
You responded ‘Yes’ to having in the last seven (7) years illegally or without authorization,
modified, destroyed, manipulated, or denied others access to information residing on an
information technology system or attempted any of the above.
27.2.1.1
Provide the date of the incident.
Month/Year

Est.

/
27.2.1.2
Provide a description of the nature of the incident or offense.

27.2.1.3
Provide the location where the incident took place.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
27.2.1.4
Provide a description of the action (administrative, criminal or other) taken as a result of this
incident.

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Section 27: Use of IT Systems

Section 27.2.0.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Modified/Destroyed/Manipulated/Denied Access to Information System Summary
Summary of Incidents
# Date of incident Location
1 02/2007

Actions

Boyers, PA

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27.2.2.1
Are there any other incidents to report?
□ Yes
□ No
Add Optional Comment

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Section 27: Use of IT Systems

Section 27.3.0.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Unauthorized / Unlawful Use of Information Technology
27.3.0.1
In the last seven (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 or attempted any of the above?
□ Yes
□ No
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Section 27: Use of IT Systems

Section 27.3.1.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Unauthorized / Unlawful Use of Information Technology Detail
You responded ‘Yes’ to having in the last seven (7) years 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 or
attempted any of the above.
27.3.1.1
Provide the date of the incident.
Month/Year

Est.

/
27.3.1.2
Provide a description of the nature of the incident or offense.

27.3.1.3
Provide the location where the incident took place.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
27.3.1.4
Provide a description of the action (administrative, criminal or other) taken as a result of this
incident.

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Section 27: Use of IT Systems

Section 27.3.2.0 - Use of Information Technology Systems
Section 27: Use of Information Technology Systems
Unauthorized / Unlawful Use of Information Technology Summary
Summary of Incidents
# Date of incident
Location
1 12/1999

Blacksburg, VA

Actions
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27.3.2.1
Are there any other incidents to report?
□ Yes
□ No
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Section 27: Use of IT Systems

Section 28 SF86 “Involvement in Non-Criminal Court Actions”
Section 28.0.0.0 - Non Criminal Court Actions
Section 28: Involvement in Non-Criminal Court Actions
28.0.0.1
In the last ten (10) years, have you been a party to any public record civil court action not listed
elsewhere on this form?
□ Yes
□ No
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Section 28: Non-Criminal Court Actions

Section 28.1.0.0 - Non Criminal Court Actions
Section 28: Involvement in Non-Criminal Court Actions Detail
You responded ‘Yes’ to having been a party to any public record civil court action(s) not listed
elsewhere on this form in the last ten (10) years.
28.1.0.1
Provide the date of the civil action.
Month/Year

Est.

/
28.1.0.2
Provide the court name.

28.1.0.3
Provide the address of the court.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
28.1.0.4
Provide details of the nature of the action.

28.1.0.5
Provide a description of the results of the action.

28.1.0.6
Provide the name(s) of the principal parties involved in the court action.

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Section 28: Non-Criminal Court Actions

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Section 28: Non-Criminal Court Actions

Section 28.2.0.0 - Non Criminal Court Actions
Section 28: Involvement in Non-Criminal Court Actions Summary
Summary of public record civil court actions
# Date of action Court
Actions
1 03/2005

4th District

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28.2.0.1
Are there any other civil court actions in the last ten (10) years to report?
□ Yes
□ No
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Section 28: Non-Criminal Court Actions

Section 29 SF86 “Association Record”
Section 29.0.0.0 - Association Record Instructions
Section 29: Association Record
The following 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, security, or
credentialing decision. 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.
Continue

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Section 29: Association Record

Section 29.1.0.0 - Association Record
Section 29: Association Record
Member of Terrorist Organization
29.1.0.1
Are you now or have you EVER been a member of an organization dedicated to terrorism, either
with an awareness of the organization’s dedication to that end, or with the specific intent to
further such activities?
□ Yes
□ No
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Section 29: Association Record

Section 29.1.1.0 - Association Record
Section 29: Association Record
Member of Terrorist Organization Detail
You responded ‘Yes’ to being or ever having been a member of an organization dedicated to
terrorism, either with an awareness of the organization’s dedication to that end, or with the
specific intent to further such activities.
29.1.1.1
Provide the full name of the organization.

29.1.1.2
Provide the address/location of the organization.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
29.1.1.3
Provide the dates of your involvement with the organization.
Date
Month/Year
Est./Pres.
From:

/

To:

/

29.1.1.4
Provide all positions held in the organization, if any.
□ No positions held

29.1.1.5
Provide all contributions made to the organization, if any.
□ No contributions made

29.1.1.6
Provide a description of the nature of and reasons for your involvement with the organization.

Section 29: Association Record

Add Optional Comment

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Section 29: Association Record

Section 29.1.2.0 - Association Record
Section 29: Association Record
Member of Terrorist Organization Detail
Summary of Associations
#
Date of association

Location Organization

1 From 05/2005 to 05/2006 Miami, FL Al-Qaida

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29.1.2.1
Do you have any other instances of being a member of an organization dedicated to terrorism,
either with an awareness of the organization’s dedication to that end, or with the specific intent
to further such activities to report?
□ Yes
□ No
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Section 29: Association Record

Section 29.2.0.0 - Association Record
Section 29: Association Record
Knowingly Engaged in Terrorism
29.2.0.1
Have you EVER knowingly engaged in any acts of terrorism?
□ Yes
□ No
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Section 29: Association Record

Section 29.2.1.0 - Association Record
Section 29: Association Record
Knowingly Engaged in Terrorism Detail
You responded ‘Yes’ to ever having knowingly engaged in any acts of terrorism.
29.2.1.1
Describe the nature and reasons for the activity.

29.2.1.2
Provide the dates for any such activities.
Date
Month/Year
Est./Pres.
From:

/

To:

/

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Section 29: Association Record

Section 29.2.2.0 - Association Record
Section 29: Association Record
Knowingly Engaged in Terrorism Summary
Summary of acts
# Date of act Location
1 05/2001

Atlanta, GA

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29.2.2.1
Do you have any other instances of knowingly engaging in acts of terrorism to report?
□ Yes
□ No
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Section 29: Association Record

Section 29.3.0.0 - Association Record
Section 29: Association Record
Advocating Acts of Terror
29.3.0.1
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S.
Government by force?
□ Yes
□ No
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Section 29: Association Record

Section 29.3.1.0 - Association Record
Section 29: Association Record
Advocating Acts of Terror Detail
You responded ‘Yes’ to having ever advocated any acts of terrorism or activities designed to
overthrow the U.S. Government by force.
29.3.1.1
Provide the reason(s) for advocating acts of terrorism.

29.3.1.2
Provide the dates of advocating acts of terrorism.
Date
Month/Year
Est./Pres.
From:

/

To:

/

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Section 29.3.2.0 - Association Record
Section 29: Association Record
Advocating Acts of Terror Summary
Summary of acts
# Date of act Location
1 09/2007

Boyers, PA

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29.3.2.1
Do you have any other instances of advocating acts of terrorism or activities designed to
overthrow the U.S. Government by force to report?
□ Yes
□ No
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Section 29: Association Record

Section 29.4.0.0 - Association Record
Section 29: Association Record
Member of Terrorist Organization
29.4.0.1
Have you EVER been a member of an organization dedicated to the use of violence or force to
overthrow the United States Government, and which engaged in activities to that end with an
awareness of the organization’s dedication to that end or with the specific intent to further such
activities?
□ Yes
□ No
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Section 29: Association Record

Section 29.4.1.0 - Association Record
Section 29: Association Record
Member of Terrorist Organization Detail
You responded ‘Yes’ to having EVER been a member of an organization dedicated to the use of
violence or force to overthrow the United States Government, and which engaged in activities to
that end with an awareness of the organization’s dedication to that end or with the specific intent
to further such activities.
29.4.1.1
Provide the full name of the organization.

29.4.1.2
Provide the address/location of the organization.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
29.4.1.3
Provide the dates of your involvement with the organization
Date
Month/Year
Est./Pres.
From:

/

To:

/

29.4.1.4
Provide all positions held in the organization, if any.
□ No positions held

29.4.1.5
Provide all contributions made to the organization, if any.
□ No contributions made

29.4.1.6
Provide a description of the nature of and reasons for your involvement with the organization.

Section 29: Association Record

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Section 29.4.2.0 - Association Record
Section 29: Association Record
Member of Terrorist Organization Summary
Summary of Associations
#
Date of association

Location

Organization

1 From 01/2003 to 01/2006 Cleveland, OH Fatah al-Islam

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29.4.2.1
Do you have any other instances of being a member of an organization dedicated to the use of
violence or force to overthrow the United States Government, which engaged in activities to that
end with an awareness of the organization’s dedication to that end or with the specific intent to
further such activities to report?
□ Yes
□ No
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Section 29: Association Record

Section 29.5.0.0 - Association Record
Section 29: Association Record
Member of Organization Advocating Violence
29.5.0.1
Have you EVER been a member of an organization that advocates or practices 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 action?
□ Yes
□ No
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Section 29: Association Record

Section 29.5.1.0 - Association Record
Section 29: Association Record
Member of Organization Advocating Violence Detail
You responded ‘Yes’ to being or ever having been a member of an organization that advocates or
practices commission of acts of force or violence to discourage others from exercising their
rights under the U.S. Constitution or that of any state of the U.S. with the specific intent to
further such action.
29.5.1.1
Provide the full name of the organization.

29.5.1.2
Provide the address/location of the organization.
Street:
City:
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State:

Zip Code:

Country:
29.5.1.3
Provide the dates of your involvement with the organization.
Date
Month/Year
Est./Pres.
From:

/

To:

/

29.5.1.4
Provide all positions held in the organization, if any.
□ No positions held

29.5.1.5
Provide all contributions (in U.S. dollars) made to the organization, if any.
□ No contributions made

29.5.1.6
Provide a description of the nature of and reasons for your involvement with the organization.

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Section 29.5.2.0 - Association Record
Section 29: Association Record
Member of Organization Advocating Violence Summary
Summary of Associations
#
Date of association

Location

Organization

1 From 03/2001 to 01/2006 Madison, WI Taliban

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29.5.2.1
Do you have any other instances of being a member of an organization that advocates or
practices 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 action to report?
□ Yes
□ No
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Section 29.6.0.0 - Association Record
Section 29: Association Record
Activities Designed to Overthrow the U.S. Government
29.6.0.1
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government
by force?
□ Yes
□ No
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Section 29.6.1.0 - Association Record
Section 29: Association Record
Activities Designed to Overthrow the U.S. Government Detail
You responded ‘Yes’ to having ever knowingly engaged in activities designed to overthrow the
U.S. Government by force.
29.6.1.1
Describe the nature and reasons for the activity.

29.6.1.2
Provide the dates of such activities.
Date
Month/Year
Est./Pres.
From:

/

To:

/

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Section 29.6.2.0 - Association Record
Section 29: Association Record
Activities Designed to Overthrow the U.S. Government Summary
Summary of activities
# Date of act Location
1 01/2000

London, UK

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29.6.2.1
Do you have any other instances of having knowingly engaged in activities designed to
overthrow the U.S. Government by force to report?
□ Yes
□ No
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Section 29.7.0.0 - Association Record
Section 29: Association Record
Terrorism Associations
29.7.0.1
Have you EVER associated with anyone involved in activities to further terrorism?
□ Yes
□ No
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Section 29.7.1.0 - Association Record
Section 29: Association Record
Terrorism Associations Detail
You responded ‘Yes’ to having ever associated with anyone involved in activities to further
terrorism.
29.7.1.1
Provide explanation.

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Section 29: Association Record

*********************Certification Block(PAPER FORM ONLY)************

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.
Signature (Sign in ink)

Date (mm/dd/yyyy)

*************END CERTIFICATION BLOCK (PAPER FORM ONLY)**********

Electronic System Name
Investigation Request #000000
SIGNATURE FORMS
The signature(s) in this document refer to information on forms submitted in the
Electronic System Name Investigation Request #000000. The signature on the
statement below is as valid as directly signing the same statement on a printed
Electronic System Name Investigation Request #000000 Official Archival Copy.
This signed statement and an image of each page from the e-QIP Investigation
Request #000000 Official Archival Copy will be considered official record.
Sign and submit all forms in this document to the office that initiated your
Investigation Request.
Data Hash Code: 3a7d97531e930256417a10e8f6adf3642fbcf70b
Official Archival Copy PDF Hash Code:
34f08d32915cdc17122850d1d294ce1c8db04c53
Date/Time Certified in the Electronic System Name: 2010-01-01 12:00:00.000
Applicant's Social Security Number: 000-00-0000

Questionnaire for National Security Positions (SF86
Format)
OMB No. 3206-0005
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.
Signature (Sign in ink)

Date (mm/dd/yyyy)

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, reinvestigation or continuous evaluation (as defined in Executive Order 12968 as amended by Executive
Order 13467) 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 United States 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.
I Authorize the information to be used to conduct officially sanctioned and approved personnel security-related studies and analyses,
which will be maintained in accordance with the Privacy Act.
Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I remain employed in
a sensitive position requiring eligibility for access to classified information.

Signature (Sign in ink)

Full name (Type or print legibly)

Other names used
Current street address Apt. #

City (Country)

State

Date signed (mm/dd/yyyy)

Date of birth

Social Security Number

ZIP Code

Home telephone number

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.
Signature (Sign in ink)

Full name (Type or print legibly)

Other names used
Current street address Apt. #

Date signed (mm/dd/yyyy)
Social Security Number

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 __NO
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
Dates of treatment?

Signature (Sign in ink)

Practitioner name

Date signed (mm/dd/yyyy)

QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
UNITED STATES OF AMERICA
FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit
Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
Information provided by you on this form will be furnished to the consumer reporting agency in order to obtain information in
connection with a background investigation to determine your (1) fitness for Federal employment, (2) clearance to perform contractual
service for the Federal government, and/or (3) eligibility for a sensitive position or access to classified information.
The information obtained may be disclosed to other Federal agencies for the above purposes in fulfillment of official responsibilities
to the extent that such disclosure is permitted by law. Information from the consumer report will not be used in violation of any
applicable Federal or state equal employment opportunity law or regulation.
Authorization
I hereby authorize the investigative agency conducting my background to obtain such reports from any consumer reporting agency for
employment purposes described above.
Note: If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation,
which can adversely affect your eligibility for a national security position. To avoid such delays, you should request that the consumer
reporting agencies lift the freeze in these instances.
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.

Print name

Social Security Number

Signature (Sign in ink)

Date (mm/dd/yyyy)