Form GSA Form 850 GSA Form 850 Temporary Contractor Information Worksheet

TEMPORARY CONTRACTOR INFORMATION WORKSHEET

OMB Number: 3090-0283

(Temporary Contractors for American Recovery and Reinvestment Act of 2009 Efforts:
Working on Contract 6 Months or Less & Require Physical Access Only)

Expires: 12/31/2012

Instructions to Complete this Form

1. Follow the instructions given to you by the person from GSA who gave you the form and any other clarifying instructions furnished by that person to
assist you in completion of the form.
2. You must sign and date, in black or blue ink, the original and submit the original to GSA.
3. Type or legibly print your answers in black or blue ink (if your form is not legible, it will not be accepted).
4. All questions in Section A on this form must be answered. If no response is necessary or applicable, indicate this on the form (for example, enter
"None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by
marking "APPROX." or "EST."
5. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, GSA may modify
the form consistent with your intent.
6. You must use U. S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.
7. All telephone numbers must include area codes.
8. All dates provided on this form must be in Month/Day/Year (mm/dd/yy) or Month/Year (mm/yy) format. Use numbers (1-12) to indicate months. For
example, May 27, 1972, should be shown as 5/27/72.
9. If you need additional space to complete the form, please use a separate blank sheet of paper.

Section A: To Be Completed By Temporary Contractor

1. Name (Last/Family)

6. Social Security Number

2. First (Given)

7. Date of Birth

3. Middle (or NMN if none)

8. Place of Birth (City and State)

11. Home Street Address

4. Other Names Used

9. Country

10. Gender

12. E-Mail Address (Optional)

13. Daytime Phone Number

15. City

19. U.S. Citizen?

5. Suffix

17. Zip Code

16. State

14. Cell Phone Number

18. Position (Job) Title

Non-US Citizens Only: Complete 20-23
20. U.S. Port of Entry City and State

21. Date of Entry

22. Alien Registration Number

23. Country of Citizenship

24. Comments (A separate blank sheet of paper can be included for comments if additional space is needed)

Section B: To Be Completed By GSA

1. Company Name

2. Company is Prime or Subcontractor?

Prime

3. If Subcontractor, Name of Prime

Subcontractor

4. Contract / Task Order / RWA Number

5. Contract Start Date

6. Contract End Date

7. Company Point of Contact (POC) Name

8. POC Daytime Phone Number

9. POC E-Mail Address

10. GSA Building Number

11. Building Name

13. Contractor Type (PBS or
Non-PBS)

14. Has Prior FBI National Criminal History Check (NCHC) on a GSA Contract
in the Last 6 Months?

16. Requesting Official’s Name

12. Building Address

17. Requesting Official’s Title

19. Requesting Official’s E-Mail Address 20. Requesting Official’s Daytime Phone Number

GENERAL SERVICES ADMINISTRATION

PAGE 1 OF 2

15. Prior NCHC Check Date

18. Is Requesting Official COR / COTR?

21. Requesting Official’s Office Symbol

22. GSA Region

GSA 850 (REV. 12/2009)

PURPOSE OF THIS FORM

The U.S. Government conducts criminal checks and Citizenship & Immigration Status
Checks to establish that applicants or incumbents working for the Government under
contract may have unescorted access to GSA-controlled facilities. GSA will use this
form and the FBI form FD-258 Fingerprint Card to conduct a FBI National Criminal
Information Check (NCIC) for each temporary contractor (working on contract 6
months or less and require physical access only) on GSA contracts for American
Recovery and Reinvestment Act of 2009 efforts only. This form: authorizes the request
for a NCIC and Citizenship & Immigration Status Check; describes the authority to
collect and share the required information; and identifies the temporary contractor to
GSA contract, building, and vendor information. A favorable entry on duty
determination from the NCIC and Central Index Check System (CIS) is required to
receive unescorted physical access to GSA-controlled facilities.

AUTHORITY TO REQUEST THIS INFORMATION

The Office of Management and Budget (OMB) Guidance M-05-24 for Homeland
Security Presidential Directive (HSPD) 12 requires Federal departments and
agencies to ensure that temporary contractors have limited/controlled access to
facilities and information systems. GSA Directive CIO P 2181.1, Homeland
Security Presidential Directive-12 Personal Identity Verification and
Credentialing, provides that GSA temporary contractors must undergo a
minimum of a FBI National Criminal Information Check (NCIC) and Citizenship &
Immigration Status Check to receive unescorted physical access. DHS/ICE/FPS
will transmit the access determination electronically to designated GSA officials
and the temporary contractor's company.

THE BACKGROUND CHECK PROCESS

GSA submits this completed form and your 10-digit fingerprints on the FBI Form
FD-258 Fingerprint Card to the U.S. Department of Homeland Security
Immigration and Customs Enforcement, Federal Protective Service (DHS/ICE/
FPS) to process the background investigation request per the terms of agreement
in two separate Memorandums of Agreement (MOAs) between GSA and DHS/
ICE/FPS. DHS/ICE/FPS conducts a pre-employment name check through the
National Crime Information Center (NCIC), Interstate Identification Index (III),
Citizenship & Immigration Status Check, and a wanted person file; and forwards
your fingerprints to the FBI to conduct a national fingerprint background check.
The FBI provides the FBI Identification Record which lists information taken from
fingerprint submissions retained by the FBI in connection with arrests and, in
some instances, Federal employment, naturalization, or military service, to DHS/
ICE/FPS to make a determination for unescorted physical access. DHS/ICE/FPS
will transmit the access determination electronically to designated GSA officials
and the temporary contractor’s company.

AUTHORIZATION AND RELEASE
I hereby authorize the U.S. General Services Administration and other
authorized Federal agencies to obtain any information required from the
Federal government and/or state agencies, including but not limited to, the
Federal Bureau of Investigation (FBI), the Defense Security Service (DSS),
the U.S. Office of Personnel Management (OPM), the U.S. Department of
Homeland Security (DHS), (if applicable). This authorization is valid for one
year from the date this form was signed or upon termination of my affiliation
with the Federal Government, whichever is sooner.
I have been notified of any employer’s right to require a criminal history
records check as a condition of contract employment with GSA. I
understand that I may request a copy of such records as may be available
to me under the law. I understand that I have a right to challenge the
accuracy and competencies of any information contained in the report. I
also understand that this information will be treated as privileged and
confidential information. Case files are handled under the procedures for
safeguarding records.
I release any individual, including records custodians, any component of
the U.S. Government or the individual State Criminal History Repository
supplying information, from all liability for damages that may result on
account of compliance, or any attempts to comply with this authorization.
This release is binding, now and in the future, on my heirs, assigns,
associates, and personal representative(s) of any nature. Copies of this
authorization that show my signature are as valid as the original release
signed by me.

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
Solicitation of information contained herein may be used as a basis for
physical access determinations. GSA describes how your information will
be maintained in the Privacy Act system of record notice published in the
Federal Register at 73 FR 35690 on June 24, 2008. Your social security
number is being requested pursuant to Executive Order 9397. Disclosure
of the information by you is voluntary. Failure to provide information
requested on this form may result in the government’s inability, to grant
unescorted physical access to GSA-controlled facilities and may affect
your prospects for employment or continued employment under a
government contract, or at a Federal facility, or with a government license.
PRIVACY ACT ROUTINE USES
1.

To GSA Personnel when needed for official business, including the Security
Office, HSPD -12 Points of Contacts, and designated analysts and managers
for official business; and PIV card requesting officials to track, verify, and
update identity information of GSA personnel; and Regional Credential Officers
(RCOs) to issue and track PIV ID cards;
2. To verify eligibility of an employee or contractor before granting access to
specific resources;
3. To disclose information to agency staff and administrative offices who may
restructure the data for management purposes;
4. An authoritative source of identities for Active Directory and Lotus Notes and
other GSA systems;
5. In any legal proceeding, where pertinent, to which GSA is a party before a court
or administrative body;
6. To authorized officials engaged in investigating or settling a grievance,
complaint, or appeal filed by an individual who is the subject of the record.
7. To a Federal, state, local, foreign, or tribal agency in connection with the hiring
or retention of an employee; the issuance of a security clearance; the reporting
of an investigation; the letting of a contract; or the issuance of a grant, license,
or other benefit to the extent that the information is relevant and necessary to a
decision;
8. To the Office of Personnel Management (OPM), the Office of Management and
Budget (OMB), or the Government Accountability Office (GAO) when the
information is required for program evaluation purposes;
9. To a Member of Congress or staff on behalf of and at the request of the
individual who is the subject of the record;
10. To an expert, consultant, or contractor of GSA in the performance of a
Federal duty to which the information is relevant;
11. To the National Archives and Records Administration (NARA) for records
management purposes;
12. To appropriate agencies, entities, and persons when (1) the Agency suspects
or has confirmed that the security or confidentiality of information in the system
of records has been compromised; (2) the Agency has determined that as a
result of the suspected or confirmed compromise there is a risk of harm to
economic or property interests, identity theft or fraud, or harm to the security or
integrity of this system or other systems or programs (whether maintained by
GSA or another agency or entity) that rely upon the compromised information;
and (3) the disclosure made to such agencies, entities, and persons is
reasonably necessary to assist in connection with GSA's efforts to respond to
the suspected or confirmed compromise and prevent, minimize, or remedy
such harm.

PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to
average 15 minutes per response, including the time to review instructions,
search existing data sources, gather and maintain data needed, and
complete and review the collection of information. Send comments
regarding this burden estimate or any other aspects of this collection of
information, including suggestions for reducing this burden, to Personnel
Security Requirements Division (CPR), General Services Administration,
Washington DC 20405.
FINAL DETERMINATION ON YOUR ACCESS PROVISIONING
Final determination on granting unescorted physical access to GSAcontrolled facilities is the responsibility of the U.S. Department of
Homeland Security, Immigrations and Customs Enforcement, Federal
Protective Service (DHS/ICE/FPS). You may be provided the opportunity
personally to explain, refute, or clarify any information before a final
decision is made.

AUTHORIZATION AND RELEASE AND CERTIFICATION

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD
RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS

I declare under penalty of perjury that
the statements made by me on this
form are true, complete and correct.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE
YOU HAVE PROVIDED ALL REQUESTED INFORMATION FULLY AND
CORRECTLY.

DATE

SIGNATURE

GENERAL SERVICES ADMINISTRATION

PAGE 2 OF 2

GSA 850 (REV. 12/2009)