SF-85 Questionnaire for Non-Sensitive and Low Risk Positions

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

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Questionnaire for Non-Sensitive Positions

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

Purpose of this Form
The United States (U.S.) Government conducts background investigations to
establish that applicants or incumbents either employed by the Government
or working for the Government under contract, are suitable for the job.
Information from this form is used primarily as the basis for this investigation.
Giving us this information is voluntary. However, we may not be able to
complete your investigation, or complete it in a timely manner, if you don't give
us each item of information we request. This may affect your placement or
employment prospects.

Authority to Request this Information
Depending upon the purpose of your investigation, the United States
Government is authorized to ask for this information under Executive Order
10450, sections 3301 and 3302 of title 5, United States Code; and parts 2, 5,
731, and 736 of title 5, Code of Federal Regulations.
Your Social Security Number (SSN) is needed to identify your unique records.
Although disclosure of your SSN is not mandatory, failure to disclose your
SSN may prevent or delay the processing of your background investigation.
The authority for soliciting and verifying your SSN is Executive Order 9397.

The Investigative Process
Background investigations for non-sensitive positions are conducted to gather
information to show whether you are reliable, trustworthy, of good conduct
and character, and loyal to the U.S. The information that you provide on this
form may be confirmed during the investigation. The investigation may extend
beyond the time covered by this form when necessary to resolve issues.
Your current employer may be contacted as part of the investigation, even if
you have previously indicated on applications or other forms that you do not
want your current employer to be contacted.

Instructions for Completing this Form
1.

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

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 certain 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 shown in an address block, also provide in
that block the name of the country when the address is outside the U.S.

7.

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

8.

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

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 find that you
cannot report an exact date, approximate or estimate the date to the
best of your ability and indicate this by writing "APPROX." or "EST."

10. If you need additional space for explanation or to list your residences,
employment/self-employment/unemployment, or education, you should
use a continuation sheet, SF 86A. If additional space is needed to
answer other items, use the Continuation Space on page 11 or a blank
sheet(s) of paper. Each blank sheet of paper you use must contain your
name and SSN at the top of the page.

Final Determination on Your Suitability
Final determination on your suitability for a non-sensitive position is the
responsibility of the Federal agency that requested your investigation.
You may be provided the opportunity personally to explain, refute, or
clarify any information before a final decision is made.

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly
falsifying or concealing a material fact is a felony which may result in fines
and/or up to 5 years of imprisonment. In addition, Federal agencies generally
fire 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 are better if you answer all questions truthfully
and completely. You will have adequate opportunity to explain any information
you give to us on this form and to make your comments part of the record.

DISCLOSURE INFORMATION
The information you give to us is for the purpose of determining your suitability
for Federal and Federal contract employment; we will protect it from
unauthorized disclosure. The collection, maintenance, and disclosure of
background investigative information is governed by the Privacy Act. The
agency that requested the investigation and the agency that conducted the
investigation have published notices in the Federal Register describing the

systems of records in which your records will be maintained. The information
on this form, and information collected during an investigation, may be
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 published by the agency in the Federal Register. The office that
gave you this form will provide you a copy of its routine uses.

PRIVACY ACT ROUTINE USES
1. To the Department of Justice when: (a) the agency or any component
thereof; or (b) any employee of the agency in his or her official capacity; or (c)
any employee of the agency in his or her individual capacity where the
Department of Justice has agreed to represent the employee; or (d) the
United States Government, is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are
both relevant and necessary to the litigation and the use of such records by
the Department of Justice is therefore deemed by the agency to be for a
purpose that is compatible with the purpose for which the agency collected the
records.
2. To a court or adjudicative body in a proceeding when: (a) the agency or
any component thereof; or (b) any employee of the agency in his or her official
capacity; or (c) any employee of the agency in his or her individual capacity
where the Department of Justice has agreed to represent the employee; or (d)
the United States Government is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are
both relevant and necessary to the litigation and the use of such records is
therefore deemed by the agency to be for a purpose that is compatible with
the purpose for which the agency collected the records.
3. Except as noted in Question 18, 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia

AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA

Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland

HI
ID
IL
IN
IA
KS
KY
LA
ME
MD

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

MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ

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

NM
NY
NC
ND
OH
OK
OR
PA
RI
SC

American Samoa
Federated States of Micronesia

AS
FM

Guam
Marshall Islands

GU
MH

Northern Mariana Islands
Puerto Rico

MP
PR

Palau
Virgin Islands of the U.S.

PW
VI

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

SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to OPM Forms Officer, U.S. Office of
Personnel Management, 1900 E Street, N.W., Washington, DC 20415. Do not send your completed form to this address; send it to the office that provided you
the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS
Codes

Investigating agency use only

Case number

AGENCY USE ONLY
For competitive service initial appointments only: when the OF 306, resume, and other information provided in 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.

A Type of investigation

B Extra coverage/Advance results

F Position title

C Nature of action code D Date of action
H SOI

G SON

K Obligating document number

E Geographic location
I IPAC

M Accounting data and/or Agency case number

L BETC

O Requesting official - Name

J TAS
N Investigative
requirement

Initial
Reinvestigation

Signature

Title

Email address

Telephone number

Date

I certify that the initial comparison of the OF 306 and the SF 85 did not reveal evidence of material falsification.
P Secondary requesting official - Name

Title
Telephone number

Email address

Q Applicant affiliation

FED CIV
MIL

CON
Other

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

1 FULL NAME

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

First name

Last name
3 PLACE OF BIRTH
City

Middle name

County

State

2 DATE OF BIRTH
Jr., II, etc.
4 SOCIAL SECURITY NO.

Country (if outside the U.S.)

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

YES

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

Name #1

Month/Year

To Month/Year

Name #2

Month/Year

To Month/Year

Name #3

Month/Year

To Month/Year

Name #4

Month/Year

To Month/Year

6A MOTHER'S MAIDEN NAME
Last name

First name

Middle name

6B FATHER'S FULL NAME
Last name

First name

Middle name

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

Eye color

Sex

Female
Male

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

Work telephone number
Day
Evening

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

Day
Mobile telephone number
Evening

Day
Evening

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

I am a naturalized U.S. citizen. Go to 9B or 9C

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

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

I am not a U.S. citizen. Go to 9D

ALIEN REGISTRATION NUMBER (if applicable)
Number

Expired

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

State

Certificate number

Date issued

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

State

Certificate number

Date issued

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

State

Country(ies) of citizenship

Type of document (I-94, etc.)

Date of entry

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

Document number

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

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

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

NO, explain

D Have you renounced or attempted to renounce your foreign citizenship(s)? (If "Yes," explain.)
NO
YES, explain
11 WHERE YOU HAVE LIVED Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 11 for additional answers.
List the places where you have lived, beginning with your present residence (#1) and working back 5 years. Residences for the entire 5 year period must
be accounted for without breaks. Indicate the actual physical location of your residence. Do not use a Post Office Box as an address, and do not list a
permanent address when you were actually living at a school address, etc. Be sure to be as specific as possible when listing an address location: for
example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations (TDY) under 90 days (list
your address of record instead), but you must list other part-time residences. Your actual physical location in addition to your APO/FPO address is required
for overseas assignments.
For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area. Do not list people for residences
completely outside this 3-year period, and do not list your spouse, former spouse, or other relatives. Also, for addresses in the last 3 years, if the address is
"General Delivery," a Rural or State Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet (SF
86A). Do not list residences before your 18th birthday unless to provide a minimum of 2 years of residence history.
Residence Information and Point of Contact for that Period of Residence
Own
Military housing
#1 Month/Year To Month/Year Status
Rent
Other (Explain)
Present

Street address

Apt.#

APO/FPO address
State

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

Current address

ZIP Code
Apt.#

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

State
Alternate contact number

Relationship

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

Neighbor

Landlord

Friend

Business associate

ZIP Code

Other (Explain)

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

Own
Rent

Military housing

Street address

Apt.#

Other (Explain)

APO/FPO address
State

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

Current address

ZIP Code
Apt.#

APO/FPO address (if currently applicable)
State

City (Country)
Telephone number

Alternate contact number

#3 Month/Year To Month/Year Status

Own
Rent

Relationship
Military housing

Neighbor

Landlord

Friend

Business associate

ZIP Code

Other (Explain)

Street address

Apt.#

Other (Explain)

APO/FPO address
State

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

Current address

ZIP Code
Apt.#

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

State

Telephone number
#4 Month/Year

Alternate contact number

To Month/Year Status

Own
Rent

Relationship
Military housing

Neighbor

Landlord

Friend

Business associate

ZIP Code

Other (Explain)

Street address

Apt.#

Other (Explain)

APO/FPO address
City (Country)

State

Name of person who knows you at this address

Current address

ZIP Code
Apt.#

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

State
Alternate contact number

Relationship

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

Neighbor

Landlord

Friend

Business associate

ZIP Code

Other (Explain)

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

12 WHERE YOU WENT TO SCHOOL Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 11 for additional answers.
List all schools you have attended, beginning with the most recent (#1) working back 5 years. List college or university degrees and the dates they were
received. If your most recent degree or diploma was received more than 5 years ago, list it below no matter when it was received.
In the Code block, show the most appropriate code to describe your school.
1 - High School
3 - Vocational/Technical/Trade School
2 - College/University/Military College
4 - Correspondence/Distance/Extension/Online School
For Correspondence/Distance/Extension/Online School, provide the address where the records are maintained.
For schools you attended in the last 3 years, list a person who knew you at school (instructor, student, etc.).
Do not list people for education periods completed more than 3 years ago.
SCHOOL INFORMATION
#1 Month/Year To Month/Year Code
Degree/diploma received? If "Yes," identify type
Name of school
of degree/diploma received and date awarded.
State

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

Current address

#2 Month/Year

To Month/Year Code

NO
ZIP Code
Apt. #

State

City (Country)

YES

ZIP Code

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

Name of school

YES
NO

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

State
Current address

#3 Month/Year

Apt. #
State

City (Country)
To Month/Year Code

ZIP Code

ZIP Code

Name of school

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

YES
NO

State

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

#4 Month/Year

Apt. #

Current address
State

City (Country)
To Month/Year Code

ZIP Code

ZIP Code

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

Name of school

YES
NO

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

State
Current address

#5 Month/Year

Apt. #
State

City (Country)
To Month/Year Code

ZIP Code

ZIP Code

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

Name of school

YES
NO

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

State
Current address

ZIP Code
Apt. #

State

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

ZIP Code

Telephone number

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

13 EMPLOYMENT ACTIVITIES Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 11 for additional answers.
List all your employment activities, beginning with the present (#1) and working back 5 years . You should list all full-time and part-time work, paid or unpaid,
consulting/contracting work, all military service duty locations, temporary military duty locations (TDY) over 90 days, self-employment, other paid work, and all
periods of unemployment. The entire period must be accounted for without breaks. EXCEPTION: Do not list employments that occurred before your 18th
birthday unless it is necessary for providing a minimum of 2 years of employment history. If you require additional space, use a continuation sheet (SF 86A).
Employer/Verifier Information. List the business name of your employer or the name of a person who can verify your self-employment or
unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You
should provide separate listings to reflect changes in your military duty locations or home ports. If you are a Federal Contractor, list company name,
not Federal agency.
Additional Periods of Activity. Complete this block if you worked for an employer on more than one occasion at the same physical location. After
entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the
additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and
information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of
employment on the lines below that information.
Employment Code: Use one of the codes listed below to identify the type of employment.
1 - Active military duty stations
2 - National Guard/Reserve
3 - U.S.P.H.S. Commissioned Corps

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

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

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

Work hours Full-time
Part-time

Employer/Verifier
Telephone number

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

State

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

Telephone number

City (Country)

State

Supervisor (if different from employer)
Name and title

ZIP Code

ZIP Code

Telephone number

Work address of supervisor
State

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

Supervisor

Month/Year

To Month/Year

Position title

Supervisor

Month/Year

To Month/Year

Position title

Supervisor

Explanation/Reason for leaving

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

ZIP Code

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

Type of Employment
Employment code
Position title/Military rank

Work hours Full-time
Part-time

Employer/Verifier
Name of employer/verifier

Telephone number

Address of employer/verifier
City (Country)

State

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

Telephone number

City (Country)

State

Supervisor (if different from employer)
Name and title

Telephone number

ZIP Code

ZIP Code

Work address of supervisor
State

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

Supervisor

Month/Year

To Month/Year

Position title

Supervisor

Month/Year

To Month/Year

Position title

Supervisor

ZIP Code

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

Type of Employment
Employment code
Position title/Military rank

Employer/Verifier
Name of employer/verifier

Work hours Full-time
Part-time
Telephone number

Address of employer/verifier
City (Country)

State

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

Telephone number

City (Country)

State

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

ZIP Code

ZIP Code

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

Telephone number

Work address of supervisor
State

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

ZIP Code

Supervisor

Month/Year

To Month/Year Position title

Supervisor

Month/Year

To Month/Year Position title

Supervisor

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

Type of Employment
Employment code
Position title/Military rank

Work hours Full-time
Part-time

Employer/Verifier
Name of employer/verifier

Telephone number

Address of employer/verifier
City (Country)

State

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

Telephone number

City (Country)

State

Supervisor (if different from employer)
Name and title

Telephone number

ZIP Code

ZIP Code

Work address of supervisor
State

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

Supervisor

Month/Year

To Month/Year

Position title

Supervisor

Month/Year

To Month/Year Position title

Supervisor

Explanation/Reason for leaving

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

ZIP Code

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

Position Title

#2
#3
13C EMPLOYMENT RECORD Respond for the timeframe of the last 5 years.
1. Has any of the following happened to you in the last 5 years? If "Yes," begin with the most recent occurrence and go backward, providing date
fired, quit, or left, and other information requested.

YES

NO

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

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

Month/Year

Specify Reason

Code

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

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

State

ZIP Code

YES

NO

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

14 SELECTIVE SERVICE RECORD
a
b

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

Explanation

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

YES

NO

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

YES

NO

a Have you EVER served in the U.S. military or the U.S. Merchant Marine?
b Have you EVER served in a foreign country's military, security forces, merchant marine, militia, or other defense forces?
c Have you EVER received a discharge that was not honorable?
d In the last 5 years, have you been subject to court martial or other disciplinary proceedings under the Uniform Code of Military Justice?
(Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and outcome(s).
If you answered "Yes" to any question above, list all details of your military service below, starting with the most recent period of service and working back.
If you had a break in service, each separate time of service should be listed.
Code (Branch of Service): Use one of the codes listed below to identify your branch of service.
1 - Air Force
2 - Army

3 - Navy
4 - Marine Corps

9 - Foreign military, defense, militia, security forces

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

5 - Coast Guard
6 - Merchant Marine

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

2 - Dishonorable

3 - Other Than Honorable

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

O

E

4 - General

5 - Bad Conduct

Status
Active Active Inactive
Duty Reserve Reserve

Air NG
State

Army NG
State

6 - Other (Explain)
Type of
Discharge Code

Country

16 PEOPLE WHO KNOW YOU WELL
List three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc., who
are collectively aware of your activities outside of the workplace, school, or neighborhoods and whose combined association with you covers at least the last 5
years. Do not list your spouse, former spouse(s), other relatives, or anyone listed elsewhere on this form.
Reference name

#1
Home or work address

Reference name

#2
Home or work address

Reference name

#3
Home or work address

Relationship to you (Check all that apply)

Dates known
Month/Year To Month/Year

Apt. #

Schoolmate

State

Neighbor

Work associate

Friend

Schoolmate

City (Country)

Day

ZIP Code

State

Neighbor

Work associate

Friend

Schoolmate

City (Country)

State

Evening

Alternate telephone no.

Telephone number

Other (Explain)
Day

ZIP Code

Relationship to you (Check all that apply)

Dates known
Month/Year To Month/Year

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

Friend

Telephone number

Other (Explain)

Relationship to you (Check all that apply)

Dates known

Apt. #

Work associate

City (Country)

Month/Year To Month/Year

Apt. #

Neighbor

Evening

Alternate telephone no.

Telephone number

Other (Explain)
Day

ZIP Code

Evening

Alternate telephone no.

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

17 POLICE RECORD
For this item, report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the
court record, or the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court
issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in
the U.S. or abroad.
a

In the last 5 years, have you been arrested for, charged with, or convicted of any offense(s)? (Omit traffic fines of less than $300.)

b

In the last 5 years, have you been imprisoned, on probation, or on parole?

c

Are you now under charges for any violation of the law?

YES

NO

If you answered "Yes" to any question above, explain below, providing information for each and every offense.
Month/Year
#1

Law Enforcement Authority/Court

City and Country (if outside U.S.)

State

ZIP Code

Offense

Action Taken

#2

18 ILLEGAL USE OF DRUGS OR DRUG ACTIVITY
The following question pertains to the illegal use of drugs or drug activity. You are required to answer the question fully and truthfully, and your
failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful response nor information YES
derived from your response will be used as evidence against you in any subsequent criminal proceeding.

NO

In the last year, have you illegally used, possessed, supplied, or manufactured any controlled substance, for example, cocaine, crack
cocaine, THC (marijuana, hashish, etc.), narcotics (opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed, crystal
methamphetamine, Ecstacy, ketamine, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP,
etc.), steroids, inhalants (toluene, amyl nitrate, etc.) or prescription drugs (including painkillers)? Use of a controlled substance includes
injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any controlled substance.

If you answered "Yes" above, provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity.
Dates of Use/Activity
Type of Controlled Substance(s)
Explain (nature of use/activity, frequency of activity and number of times used)
Month/Year To Month/Year
#1
#2

19 FINANCIAL RECORD
Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts
to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "Yes," provide
the type, length, and amount of the delinquency or default and steps that you are taking to correct the error or repay the debt.

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

YES

NO

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

CONTINUATION SPACE

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

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

Certification

My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I
have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine
or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my
employment prospects or job status, up to and including my removal and debarment from Federal service.
Signature

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

Date (mm/dd/yyyy)

Standard Form 85
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

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

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

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

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation, to obtain any information relating to my activities from individuals, schools,
residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection
agencies, retail business establishments, or other sources of information. This information may include, but is not limited to,
my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history record
information, and financial and credit information. I authorize the Federal agency conducting my investigation to disclose the
record of my background investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility for a non-sensitive position.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security
Number, and date of birth with information in SSA records and provide the results of the match) to the Office of Personnel
Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I
authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my
investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other
sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of
Investigation, the Department of Defense, the Department of State, and any other authorized Federal agency, to request
criminal record information about me from criminal justice agencies for the purpose of determining my suitability for a nonsensitive position. 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 85, and that it may be disclosed by the Government only as
authorized by law.
Photocopies of this authorization that show my signature are valid. This authorization is valid for two (2) years from the date
signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.

Full name (Type or print legibly)

Signature (Sign in ink)
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