Form 3064-1600/04 Background Investigation Questionnaire for Contractor Pe

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OMB NUMBER: 3064-0072
EXPIRATION DATE: 08/31/2008

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE
FOR CONTRACTOR PERSONNEL AND SUBCONTRACTORS
INSTRUCTIONS: Type or Print Legibly. Complete each item on this form, as applicable. See Page 3 for Estimated Reporting
Burden and the Privacy Act Statement.
SECTION I - GENERAL INFORMATION
1. Full Name (Last, First, MI)

2. Social Security Number

3. Sex

4. Date of Birth

6. Are you a U.S. Citizen?

Male
Female
7. Country (If not U.S. Citizen)

5. Place of Birth (City and State)

8. Race

Yes
10. Weight

9. Height

No (If “No,” complete item 7.)
11. Eye Color

12. Hair Color

13. Other Names Used (e.g.., maiden name, names from former marriages, or aliases. Include the dates when used.)
Name
Date
Name

Date

Name

Date

Date

Name

14. Residential Address (Start with current address and work backwards 10 years. Use a separate sheet of paper, if necessary.)
Month/Year
(From)

Month/Year
(To)

15. Employer’s Name

Street Address
(Include City, State, and ZIP Code)

16. Office Telephone Number

17. Employer’s Address (Include City, State, and ZIP Code)
18. Title/Position
20. Contract Number

19. Years with Employer
21. Name of Oversight Manager

SECTION II – DISCLOSURE
INSTRUCTIONS: Check one box for each of the following questions. If your response is “Yes” to any of the questions listed below, provide a
detailed explanation including dates, names, and the locations of the event(s) in question on a separate sheet of paper and attach to this form.
22. Have you ever been employed by the RTC/FDIC?............................................................................................

Yes

No

23. Have you ever been convicted of a felony? (If “Yes,” provide the offense, law enforcement authority and/or
court, city and state, and disposition of charges.)……………….………………………………………………………………

Yes

No

24. Have you been removed from or prohibited from participating in the affairs of any FDIC-insured depository
institution because of a Federal banking agency action?...................................................................................

Yes

No

25. Have you demonstrated a pattern or practice of defalcation regarding obligations? (See Page 2)……………………...

Yes

No

26. Have you caused a substantial loss to Federal deposit insurance funds? (See Page 2)…………………………………..

Yes

No

27. Have you defaulted on a material obligation to any insured depository institution during the past 5 years?
(See Page 2) (If “Yes,” list and describe on a separate sheet of paper.)………………………………………….………..

Yes

No

28. Have you ever been employed by a Financial Institution? (If “Yes,” complete information below.)……………………

Yes

No

Financial Institution (Include City and State)

FDIC 1600/04 (10-05)

Date of Employment

QUESTION 25.

When is there a pattern or practice of defalcation? (12 CFR § 366.4)

You have a pattern or practice of defalcation under 12 CFR Section 366.3(c) when you, any person that owns or controls you, or any entity you
own or control (see Note below) has a legal responsibility for the payment on at least two obligations that are:
a. To one or more FDIC-insured depository institutions;
b. More than ninety (90) days delinquent in the payment of principal, interest, or a combination thereof; and
c. More than $50,000 each.
QUESTION 26.

What causes a substantial loss to a Federal deposit insurance fund? (12 CFR § 366.5)

You cause a substantial loss to a Federal deposit insurance fund under 12 CFR Section 366.3(d) when you, or any person that owns or controls
you, or any entity you own or control (see Note below) has:
a. An obligation to us that is delinquent for ninety (90) days or more and on which there is an outstanding balance of principal, interest, or a
combination thereof of more than $50,000;
b. An unpaid final judgment in our favor that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a
bankruptcy proceeding;
c. A deficiency balance following foreclosure of collateral on an obligation owed to us that is in excess of $50,000, regardless of whether it
becomes discharged in whole or in part in a bankruptcy proceeding; or
d. A loss to us that is in excess of $50,000 that we report on IRS Form 1099C, Information Reporting for Discharge of Indebtedness.
QUESTION 27. What is a default on a material obligation? (12 CFR § 366.13 (b))
A default on a material obligation occurs when a loan or advance with an outstanding balance of more than $50,000 is or was delinquent for
ninety (90) days or more.
NOTE: How is my ownership or control determined? (12 CFR § 366.6)
a. Your ownership or control is determined on a case-by-case basis and depends on the specific facts of your situation and the particular
industry and legal entity involved. You must provide documentation to us to use in determining your ownership or control.
b. The interest of a spouse or other family member in the same organization is imputed to you in determining your ownership or control.
c. The following are examples of when your ownership or control may or may not exist. The examples are not inclusive.
(1) You have control if you are the president or chief executive officer of an organization.
(2) You have ownership or control if you are a partner in a small law firm.
(3) You have control if you are a general partner of a limited partnership. You have ownership of control if you have a limited partnership
interest of twenty five percent (25%) or more.
(4) You have ownership or control if you have the:
(i)

Power to vote, directly or indirectly, 25% or more interest of any class of voting stock of a company;

(ii)

Ability to direct in any manner the election of a majority of a company’s directors or trustees; or

(iii)

Ability to exercise a controlling influence over the company’s management and policies.

FDIC 1600/04 (10-05) Page 2

SECTION III – AUTHORIZATION TO RELEASE INFORMATION AND CERTIFICATION
Carefully read the authorization to release information and the certification below, then sign and date in ink.
I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information, the information provided in
my resume or other personal data in order to verify my fitness and integrity to provide services for the Federal Deposit Insurance Corporation.
The background investigation I am authorizing may require information contained herein and acquired during the investigation to be disclosed to
third parties, including credit-reporting businesses and state and local licensing agencies. I hereby authorize and give my consent to such
disclosures. This authorization will remain valid for the life of the contract or until termination of my employment or affiliation with the
contractor, whichever is sooner. Photocopies of this authorization that show my signature are as valid as the original signed by me. (Pursuant to
section 604 of the Fair Credit Reporting Act, a separate notice in writing pertaining solely to obtaining a credit/consumer report will be provided
to you. See 15 U.S.C. § 1681b(2)(A)).
I certify that I have read and understood each question asked of me on this form, and that the information provided, including attachments to this
form, is true and correct to the best of my knowledge, information, and belief. I understand that anyone who knowingly or willfully makes false
or fraudulent statements or representations in connection with disclosures or certifications herein may be subject to fines and/or imprisonment or
both (18 U.S.C. § 1001 and § 1007). I agree to notify the FDIC immediately of any change in circumstances that would require disclosure
hereunder.

32. PRINT OR TYPE NAME

32. SIGNATURE (Sign in ink)

DATE

ESTIMATED REPORTING BURDEN
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing the
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, Washington, D.C.
20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.

PRIVACY ACT STATEMENT
Collection of this information is authorized by the Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1822(f)(3) and (4)), Executive
Order 9397, as well as the FDIC regulations at 12 CFR Part 366. The requested information will be used by FDIC personnel to conduct
background investigations of contractors seeking to provide services to the FDIC to determine whether the individual meets the FDIC's fitness and
integrity standards. Specifically, the information provided may be disclosed to third parties including credit-reporting businesses and state and
local licensing agencies as necessary to conduct the background investigation authorized herein.
Disclosure of information on this form may also be made to appropriate Federal or state agencies if a violation or possible violation of a civil or
criminal law is apparent; to the General Accounting Office for inspection by auditors; and, to a Congressional office in response to an inquiry
made at the request of the individual or in accordance with the other "routine uses of records" listed in the FDIC's Financial Information System
30-64-0012. Your Social Security Number (SSN) is requested to ensure record accuracy. Completion of this form is voluntary, but failure to
provide the requested information, including your SSN, may preclude you and your employer from consideration for the award of a particular
contract.

FDIC 1600/04 (10-05) Page 3