Form SF 86 SF 86 Questionnaire for National Security Positions

Questionnaire for National Security Positions
OMB No. 3206–0005
Form: SF 86

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Interactive/Branching
Electronic Questionnaire

Questionnaire Content Guide

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(DRAFT)

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FOR REFERENCE ONLY
NOT A FORM FOR COMPLETION

Federal Register /
DRAFT PRE-DECISIONAL DELIBERATIVE

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 (SF 86)” data for investigative purposes are subject to OMB review and approval.

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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.

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OFFICE OF PERSONNEL MANAGEMENT
Questionnaire for National Security Positions, SF 86
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.

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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 may become 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.

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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, as amended by EO 13478.
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, your 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 or legally recognized civil union/domestic partner, 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.

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The information you provide on this form may be confirmed during the investigation, and may be used for identification purposes throughout the investigation process.
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 as soon as possible 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.

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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
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. 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.
6. For telephone numbers in the U.S., ensure that the area code is included.
7. 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.
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 prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), 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.

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You will not receive prior notice of such disclosures under a routine use.
In addition to those disclosures generally permitted under the Privacy Act, all or a portion of the records or information you provide on this form or during your investigation may
be disclosed outside of OPM as a routine use as outlined below.
Office of Personnel Management (OPM) Routine Uses
OPM has published the following Privacy Act routine uses for its system of records for background investigations:
a. To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government or the Government
of the District of Columbia having a need to investigate, evaluate, or make a determination regarding loyalty to the United States; qualifications, suitability, or fitness for Government
employment or military service; eligibility for logical or physical access to federally-controlled facilities or information systems; eligibility for access to classified information or to
hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.
b. To an element of the U.S. Intelligence Community as identified in E.O. 12333, as amended, for use in intelligence activities for the purpose of protecting United States national
security interests.
c. To any source from which information is requested in the course of an investigation, 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.
d. To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or
order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.

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e. To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with its current
employee’s, contractor employee’s, or military member’s retention; loyalty; qualifications, suitability, or fitness for employment; eligibility for logical or physical access to federallycontrolled facilities or information systems; eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the
Government under contract, grant, or other agreement; or access to restricted areas.
f. To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from
the subject of the investigation.
g. To disclose information to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government.

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h. For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative
support.
i. To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.

j. To appropriate agencies, entities, and persons when (1) OPM suspects or has confirmed that there has been a breach of the system of records; (2) OPM has determined that as a
result of the suspected or confirmed breach there is a risk of harm to individuals, the agency (including its information systems, programs and operations), the Federal Government, or
national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with OPM’s efforts to respond to the suspected or
confirmed breach or to prevent, minimize, or remedy such harm.
k. To another Federal agency or Federal entity, when OPM determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in
(1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the agency (including its information systems, programs
and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.
l. To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, when the
Government is a party to the judicial or administrative proceeding. In those cases where the Government is not a party to the proceeding, records may be disclosed if a subpoena has
been signed by a judge.
m. To disclose information to the National Archives and Records Administration for use in records management inspections.

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n. To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which OPM is authorized to appear,
when:
(1)
OPM, or any component thereof; or
(2)
Any employee of OPM in his or her official capacity; or
(3)
Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or
(4)
The United States, when OPM determines that litigation is likely to affect OPM or any of its components;
is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OPM is deemed by OPM to be relevant and necessary to the
litigation, provided, however, that the disclosure is compatible with the purpose for which records were collected.

o. For the Merit Systems Protection Board--To disclose information to officials of the Merit Systems Protection Board or the Office of the Special Counsel, when requested in
connection with appeals, special studies of the civil service and other merit systems, review of OPM rules and regulations, investigations of alleged or possible prohibited personnel
practices, and such other functions, e.g., as promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by law.

p. To disclose information to an agency Equal Employment Opportunity (EEO) office or to the Equal Employment Opportunity Commission when requested in connection with
investigations into alleged or possible discrimination practices in the Federal sector, or in the processing of a Federal-sector EEO complaint.

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q. To disclose information to the Federal Labor Relations Authority or its General Counsel when requested in connection with investigations of allegations of unfair labor practices or
matters before the Federal Service Impasses Panel.
r. To another Federal agency’s Office of Inspector General when OPM becomes aware of an indication of misconduct or fraud during the applicant’s submission of the standard forms.

s. To another Federal agency’s Office of Inspector General in connection with its inspection or audit activity of the investigative or adjudicative processes and procedures of its agency
as authorized by the Inspector General Act of 1978, as amended, exclusive of requests for civil or criminal law enforcement activities.

t. To a Federal agency or state unemployment compensation office upon its request in order to adjudicate a claim for unemployment compensation benefits when the claim for benefits
is made as the result of a qualifications, suitability, fitness, security, identity credential, or access determination.

u. To appropriately cleared individuals in Federal agencies, to determine whether information obtained in the course of processing the background investigation is or should be
classified.
v. To the Office of the Director of National Intelligence for inclusion in its Scattered Castles system in order to facilitate reciprocity of background investigations and security
clearances within the intelligence community or assist agencies in obtaining information required by the Federal Investigative Standards.

w. To the Director of National Intelligence, or assignee, such information as may be requested and relevant to implement the responsibilities of the Security Executive Agent for
personnel security, and pertinent personnel security research and oversight, consistent with law or executive order.

x. To Executive Branch Agency insider threat, counterintelligence, and counterterrorism officials to fulfill their responsibilities under applicable Federal law and policy, including but
not limited to E.O. 12333, 13587 and the National Insider Threat Policy and Minimum Standards.
y. To the appropriate Federal, State, local, tribal, foreign, or other public authority in the event of a natural or manmade disaster. The record will be used to provide leads to assist in
locating missing subjects or assist in determining the health and safety of the subject. The record will also be used to assist in identifying victims and locating any surviving next of kin.
z. To Federal, State, and local government agencies, if necessary, to obtain information from them which will assist OPM in its responsibilities as the authorized Investigation Service
Provider in conducting studies and analyses in support of evaluating and improving the effectiveness and efficiency of the background investigation methodologies.
aa. To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with the
classifying of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to

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the requesting agency’s decision on the matter.
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 U.S. Office of Personnel Management, Federal Investigative Services, Attn: OMB Number 3206-0005,
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.
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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
YES NO
clearance, and/or removal and debarment from Federal Service.

Agency Use Block “AUB”

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Investigating agency user only
Codes:
(FIPC CODES)
Case Number:
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.
A – Type of Investigation
B – Extra coverage / advanced results
C – Sensitivity level
D – Access / Eligibility
E – Nature of action code
F – Date of action
G – Geographic location
H – Position code
I – Position title
J – SON (Submitting Office Number )
K – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other
Other address / web address of e-OPF
Zip Code
L – SOI (Security Office Identifier)
M – Location of Security Folder _ None _ NPI _ At SOI _ Other
Other address
Zip Code
N – IPAC
O – TAS
P – Obligating document number
Q - BETC
R – Accounting data and /or Agency case number
S – Investigative requirement _Initial _Reinvestigation
T – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date
U – Secondary Requesting Official: Name, Title, Email Address, Telephone Number
V – Applicant Affiliation _FED_CIV_CON_MIL_Other
W – Deployment/PCS (if Imminent):
From-To Dates, Estimated, Permanent Relocation, Reason(s) for temporary duty assignment or PCS, point of contact at location, Telephone number
(Include Ext.), Address/Unit/Duty location (Include City or Post Name)
Agency Special Instructions for the Investigative Service Provider:
Cage Code
Contracting Number

Beginning of Questionnaire

FOR REFERENCE ONLY, NOT A FORM FOR COMPLETION

Section 1 – Full Name

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.

Section 2 – Date of Birth
Provide your date of birth.

Date __-__-____

Last
name:

First
name:

Middle
name:

Suffix

Estimated □

Section 3 – Place of Birth

City

County

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Provide your Place of birth.

Section 4 – SSN

Provide your U.S. Social Security Number.

State

Country

□ Not applicable _ _ _-_ _-_ _ _ _

Section 5 – Other Names Used

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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)).
Have you used any other names?
YES
NO
Provide your other name used and the period of time you used it [for example: your maiden name, name(s) by a former
Branch
marriage(s), former name(s), alias(es), or nickname(s)]. If you have only initials in your name, provide them and indicate “Initial
If Yes to
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.
“Other
Provide other name used.
Last name:
First
Middle
Suffix
Maiden name?
YES NO
Names”
name:
name:
Provide dates used.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple
Provide the reason(s) why the name changed.
Reason: (Free Text)
Entries
Summary of other names used:
Allowed)
Do you have additional names to enter?
Yes (Yes adds another entry)
No (Required to pass validation)

Section 6 – Your Identifying Information
Provide your Identifying Information

Height

(feet)

(inches)

Weight (in pounds)

Hair Color

Eye Color

Sex (M/F)

Section 7 – Your Contact Information
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your
background investigation.
Provide your contact information.
Home email address
Email (Free Text)
Work email address
Email (Free Text)
Email addresses may be used as a
contact method, and identify subject
in records.
Home telephone number
Work telephone number
Mobile/Cell telephone number
Extension Time Day Night Both
Extension Time Day Night Both
Extension Time Day Night Both
__Check box if International or DSN __Check box if International or DSN phone number
__Check box if International or DSN phone
phone number
number
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Section 8 – U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
YES
NO
Provide the following information for the most recent U.S. passport you currently possess:
Provide your U.S. passport number.
Passport (Free Text)
Branch
Click HERE for U.S. State Department passport help. http://travel.state.gov/passport
Provide the issue date of passport.
Date __-__-____
Provide the expiration date of passport.
Date __-__-____
If Yes to
Estimated □
Estimated □
“passport”
Provide the name in which passport was first issued.
Last
First name:
Middle name:
Suffix
name:

Section 9 – Citizenship

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Select the box that reflects your current citizenship status and click Save.
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 a derived U.S. citizen □ I am not a U.S.
citizen.
You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide type of documentation of U.S. citizen born abroad.
Explanation
FS 240, DS 1350, FS 545, Other (Provide explanation)
Provide document number for U.S. citizen born abroad:
Document Number (Free Text)
Branch
Provide the date the document was issued.
Date __-__-____ Estimated □
Provide the place of issuance.
City
State
Country
Foreign Born
Last name:
First name:
Middle name:
Suffix
to U.S. Parents Provide the name in which document was issued.
in a Foreign
Provide your Certificate of Citizenship number.
Certificate Number (Free Text)
Country
Provide the date the certificate was issued.
Date __-__-____ Estimated □
Provide the name in which the certificate was issued.
Last name:
First name:
Middle name:
Suffix
Were you born on a U.S. military installation?
YES
NO
You answered that you were born on a U.S. military installation.
Branch If Yes
Provide the name of the base.
Name (Free
Text)
You answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S.
Date __-__-____ Estimated □
Provide the location of entry into the U.S.
City
State
Provide country(ies) of prior citizenship.
Country (Allows for Multiples)
Do/did you have a U.S. alien registration number?
YES
NO
Branch If Yes
Provide your U.S. alien registration number on Certificate
Alien Registration Number (Free
Branch
of Naturalization USCIS, CIS, or INS registration, I-551,
Text)
I-766.
Citizenship
Provide your Certificate of Naturalization number (N550 or N570).
Certificate of Naturalization number
Naturalized
(Free Text)
U.S. Citizen
Provide the name of the court that issues the Certificate of Naturalization.
Court (Free Text)
Provide the address of the court that issued the Certificate of Naturalization.
Street
City
State
Zip
Provide the date the Certificate of Naturalization was issued.
Date __-__-____ Estimated □
Provide the name in which the Certificate of Naturalization was issued.
Last name:
First name:
Middle name:
Suffix
Provide the basis of naturalization. - Based on my own individual naturalization application,
Explanation
- Other (Provide explanation)
You answered that you are a derived U.S. citizen.
Branch
Provide your alien registration number (on Certificate of Citizenship—
Alien Registration number. (Free Text)
utilize USCIS, CIS or INS registration number).
U.S.
Provide your Permanent Resident Card number (I-551)
Permanent Resident Card number (I-551) (Free
Citizenship
Text)
Derived
Provide your Certificate of Citizenship number (N560 or N561)
Certificate of Citizenship number (N560 or N561)
(Free Text)
Provide the name in which the document was issued.
Last name:
First
Middle
Suffix:
name:
name:
Provide the date the document was issued.
Date __-__-____ Estimated □
Provide the basis of derived citizenship. - By operation of law through my U.S. citizen parent. - Other (Provide
Explanation
explanation)
Not a U.S. Citizen
Provide your residence status.
Status (Free Text)
Provide your date of entry into the U.S.
Date __-__-____
Estimated □
Provide your country(ies) of citizenship: Allow multiple
Provide your place of entry in the U.S.
City (Free Text)
State
Branch
Provide your alien registration number. (I-551, I-766)
Registration Number (Free Text)
Provide document expiration date (I-766 ONLY).
Date __-__-____ Estimated □
Citizenship
Provide type of document issued. (I-94, U.S. Visa-red foil
I-94, U.S. Visa (red foil number), I-20, DS-2019,
Explanation
Not a U.S.
number, I-20, DS-2019, etc.)
Other (Provide explanation)
citizen
Provide document number.
Document Number (Free Text)
Provide the name in which the document was issued.
Last name:
First name:
Middle name:
Suffix:
Provide the date document
Date __-__-____ Estimated □ Provide document expiration
Date __-__-____ Estimated □
was issued.
date.

Section 10 – Dual/Multiple Citizenship & Foreign Passport Information
Do you now or have you EVER held dual/multiple citizenships?
YES NO
You answered “Yes” to having EVER held dual/multiple citizenship
Branch
Provide country of citizenship.
During what period of time did you hold citizenship with this country?
Dual/Multiple
Provide the date range that you held this citizenship, beginning with the date it was
From Date
To Date
Citizenship
acquired through its termination or “Present,” whichever is appropriate.
(Estimated)
(Estimated/Present)
How did you acquire this non-U.S.
citizenship
you now have or
previously had?
How (Free Text)
DRAFT
PRE-DECISIONAL
DELIBERATIVE

Have you taken any action to renounce your foreign citizenship?
YES NO
Provide explanation: (Free Text)
Do you currently hold citizenship with this country?
YES NO
Branch
If Present/Current
Provide explanation:
Summary of dual/multiple citizenships you have listed: Allow multiple
Select Country Value
Dates of Citizenship
Actions
Do you have an additional citizenship to provide?
YES (Yes adds another entry)
NO (Required to validate)
Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?
YES NO
You responded “Yes” to having been issued a passport (or identity card for travel) by a country other than the U.S.
Provide the country in which the passport (or identity card) was issued.
Country:
Provide the date the passport (or identity card) was issued.
Date __-__-____ Estimated □
Branch
Provide the place the passport (or identity card) was issued.
City
Country
Provide the name in which passport (or identity card) was issued:
Last
First
Middle
Suffix
Foreign
name:
name:
name:
Passport (or
Provide the passport (or identity card) number.
Passport# (Free Text)
Identity Card)
Provide the passport (or identity card) expiration date.
Date __-__-____ Estimated □
Have you EVER used this passport (or identity card) for foreign travel?
YES NO
(Multiple
Provide the countries to which you traveled on this
Country
From Date
To Date
Branch
Entries
(Multiple Entries Allowed) passport (or identity card) and the dates involved with
(Estimated)
(Est/Pres)
Allowed)
each.
Do you have an additional foreign passport (or identity card) to
YES
NO
report?
(Yes adds another entry)
(Required to validate)

Section 11 – Where You Have Lived

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(Multiple
Entries
Allowed)

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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.

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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 for residences completely outside this 3 year period, and do not list your spouse, cohabitant or other relatives as the verifier for periods of
residence.
Enter residence information. (Multiple Entries Allowed)
Provide dates of residence.
From Date (Estimated)
To Date (Estimated/Present)
Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation)
Explanation (Free Text)
Provide the street address.
Street address and City
Provide the country if outside the United States; otherwise provide
State
Zip Code
Country
State and Zip Code.
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country
Branch
Physical
location or home port/fleet headquarter. Provide physical location data:
Location
Street Address/Unit/Duty Location:
City or Post Name
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the United States.
Branch
APO/FPO
Do/did you have an APO/FPO address while at this location?
YES NO
Address
Branch If Yes
Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code Zip Code
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
Last
First
Middle
Suffix Provide date of last contact:
Date __-__-____
Provide the full name:
name: name: name:
Estimated □
Provide your relationship to this person (check all that apply)
□ Neighbor □ Friend □ Landlord □ Business associate
□ Other (Provide explanation) Explanation (Free Text)
Provide the following contact information for this person :
Provide evening phone number for this person: Number/Ext
Provide daytime phone number for this person: Number/Exte
ension
nsion
_Check box
_Check box
if
if
international
international
Branch
_I don’t
_I don’t
know
know
Person Who
Provide cell/mobile phone number for this person:
Number/Extension _Check box if international
Knew you
_I don’t know
Provide e-mail address for this person:
Email (Free Text) I don’t know □
(if address
Provide street address for this person (including apartment
Street address
City
dates within
number).
last 3 years)
Provide the country if outside the United States; otherwise
State
Zip Code
Country
provide State and Zip Code.
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name
Location
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the U.S.
Branch
Does the person who knew you have an APO/FPO address?
YES NO
APO/FPO
Branch You have indicated that the person who knew you well has or had an APO/FPO address.
Address
Branch If Yes Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code
Zip Code
Do you have an additional residence to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 12 – Where You Went toDRAFT
SchoolPRE-DECISIONAL

DELIBERATIVE

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Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed)
Have you attended any schools in the last 10 years?
YES NO
Branch If No to Attending Schools
Have you received a degree or diploma more than 10 years ago?
YES NO
Provide the dates of attendance.
From Date (Estimated)
To Date (Estimated/Present)
Select the most appropriate code to describe your school. □ High School □ College/University/Military College
□ Vocational/Technical/Trade School □ Correspondence/Distance/Extension/Online School
Provide the name of the school:
Name (Free Text)
Provide the street address of the school. For correspondence/distance/
Street address
City
extension/online schools, provide the address where the records are maintained.
For assistance determining the school address, refer to
http://ope.ed.gov/accreditation/search.aspx
Provide the country if outside the United States; otherwise provide State and Zip
State
Zip Code
Country
Branch
Code.
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
If Yes to
education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew
Attending
you while you received this education.
Schools
Provide the name of person who knows/knew you at school: □
Last name:
First name:
Initial Only □
I don’t know
No First Name □
OR
Provide current address for this person (including apartment number).
Street
City
Provide the country if outside the United States; otherwise provide State and Zip
State
Zip Code
Country
Yes to
Code.
Receiving a
Provide telephone number for this person.
Number/Extension Time Day Night Both
Degree or
_Check box if International or DSN phone
Diploma
number
Provide email address for this person: □ I don’t know
Email (Free Text)
Did you receive a degree/diploma?
YES NO
Provide type of degrees(s)/diploma(s) received and date(s) awarded:
Branch
Degree/diploma
• High School Diploma
Other degree/diploma
If Yes to
• Associate’s • Bachelor’s • Master’s • Doctorate
Other Degree (Free Text)
Receiving Degree
• Professional Degree (e.g. MD, DVM, JD) • Other
Month / Year Date __-__-____ Estimated □
Do you have additional education to enter (include education within the last 10
YES (Yes adds
NO (Required to validate)
years, as well as degrees or diplomas more than 10 years ago)?
another entry)

Section 13a – Employment Activities – Employment & Unemployment Record

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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. Provide separate entries for employment activities with the same employer but having different physical
addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.
(Multiple Entries Allowed)
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)
Other Type Explanation (Free Text)
Provide dates of employment. From Date (Estimated)
To Date (Estimated/Present)
Active Duty, National Guard/Reserve, or USPHS Commissioned Corps
Select the employment status for this position: □ Full-time □ Part-time
Provide your assigned duty
Duty station (Free Text)
Provide your most recent
Rank/position (Free Text)
station during this period.
rank/position title.
Provide address of duty station.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code.
Telephone number.
Number/Extension Time Day Night Both _Check box if
International or DSN phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post,
Branch
embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
Branch
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
If Employment
Address
Branch If Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State Zip Code
Type is Active
Duty, National
Provide the name of your supervisor.
Supervisor name (Free Text)
Guard/Reserve,
Provide the rank/position title of your supervisor.
Supervisor rank/position (Free Text)
or USPHS
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Commissioned
Provide the physical work location of your supervisor.
Street address
City
Corps
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code.
Provide supervisor telephone number.
Number/Extension Time Day Night Both _Check box if
International or DSN phone number
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. Provide physical location
Branch
data of your supervisor:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or
State
Zip Code
Country
country location.
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State Zip Code
Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other
Branch
DRAFT PRE-DECISIONAL DELIBERATIVE

Provide most recent position title.
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employer.
Provide the address of employer.
Street address
Provide Country if outside the United States; otherwise,
State
provide State and Zip Code.
Provide telephone number.

Position (Free Text)
Employer name (Free Text)
City
Zip Code
Country

Number/Extension Time Day
Night Both _Check box if
International or DSN phone
number
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on
more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3
separate periods of time, you would enter information concerning the most recent period of employment above, and provide
dates, position titles, and supervisors for the two previous periods of employment as entries below). Not Applicable □
(Multiple Entries Allowed)
Dates of employment
From Date (Estimated)
To Date (Estimated/Present)
Position title
Position (Free Text)
Supervisor
Supervisor (Free Text)
Is/was your physical work address different than your employer’s address?
Y
NO
E
S
Provide the work address where you are/were physically located.
Street Address City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code.
Provide telephone number:
Number/Ext.
You have indicated an APO/FPO address; provide physical location data with either street address, base, post,
Branch
embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Provide APO/FPO address: Address
APO/FPO
APO/FPO
Zip Code
Address
Branch if Yes
State
Provide the name of your supervisor.
Supervisor name (Free Text)
Provide the position title of your supervisor.
Supervisor position (Free
Text)
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Provide the physical work location of your supervisor.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Provide the telephone number for this supervisor.
Number/Extension Time
Day Night Both _Check
box if International or DSN
phone number
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. Provide physical location
Branch
data of your supervisor:
Physical
Location
Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State Zip Code
Self-Employment
Provide most recent position title.
Position (Free Text)
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employment
Employment
name (Free Text)
Provide the address of employment.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Provide telephone number.
Number/Extension Time Day
Night Both _Check box if
International or DSN phone
number
Is your physical work address different than your employment address?
YES NO
Provide the work address where you are/were physically located.
Street address
City
Provide Country if outside the United States; otherwise, provide
State
Zip Code
Country
State and Zip Code.
Branch
Physical
Provide telephone number:
Number/Extension Time Day
Location
Night Both _Check box if
International or DSN phone
number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post,
Branch
embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State Zip Code
Provide the name of someone that can verify your self-employment.
Last name:
First name:
DRAFT PRE-DECISIONAL DELIBERATIVE

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If Employment
Type is Other
Federal
employment,
State
Government,
Federal
Contractor, Nongovernment
employment, or
Other

Branch

If Employment
Type is SelfEmployment

Branch

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Branch
If Employment
Type is
Unemployment

Provide the address of this verifier.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Provide the telephone number for this person.
Number/Extension Time Day Night Both _Check box if
International or DSN phone number
You have indicated an APO/FPO address for your self-employment verifier; provide physical location data with
Branch
either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide
Verifier
physical location data for this person.
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
You have indicated an address outside of the United States. Does your self employment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Unemployment
Provide the name of someone who can verify your unemployment activities and means of
Last name:
First name:
support.
Provide the address of this verifier.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Provide the telephone number for this person.
Number/Extension Time Day Night Both _Check box if
International or DSN phone number
You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with
Branch
either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide
Verifier
physical location data for this person:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
You have indicated an address outside of the United States. Does your unemployment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Provide the reason for leaving the employment activity.
Reason (Free Text)
For this employment have any of the following happened to you in the last seven (7) years?
YES NO
• 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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Select the type of incident: • Fired • Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
If Employment
Branch
• Left by mutual agreement following notice of unsatisfactory performance
Type is Active
Provide the reason for being fired.
Reason (Free Text)
Branch
Duty, National
If Fired, Quit,
If Fired
Provide the date you were fired.
Date/ Estimated □
Guard/Reserve,
Left by Mutual
Provide the reason for quitting.
Reason (Free Text)
Branch
USPHS
Agreement, or
Provide the date you quit after being told you would be
Date/ Estimated □
If Quit
Commissioned
Left After
fired.
Corps, Other
Unsatisfactory
Provide the charges or allegations of misconduct.
Charges (Free Text)
Federal
Performance
Branch
Provide the date you left following charges or allegations
Date/ Estimated □
employment,
If Left after Charges
of misconduct.
State
(Multiple
Provide the reason(s) for unsatisfactory performance.
Reason (Free Text)
Branch
Government,
Entries
If Left Unsatisfactory Provide the date you left by mutual agreement following a Date/ Estimated □
Federal
Allowed)
performance
notice of unsatisfactory performance.
Contractor, NonIn the last seven (7) years do you have another reason for leaving to
YES (Yes adds
NO (Required
government
report for this employment?
another entry)
to validate)
employment,
For this employment, in the last seven (7) years have you received a written warning, been officially
YES NO
Selfreprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?
Employment,
Officially reprimanded, suspended, or disciplined for misconduct.
Branch
Unemployment,
If Disciplined,
Provide the month and year you were warned, reprimanded, suspended or
Date/ Estimated □
or Other
Warned,
disciplined.
Reprimanded, or
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Reason (Free Text)
Suspended
Do you have another instance of discipline or a warning to
YES (Yes adds
NO (Required
(Multiple Entries
provide?
another entry)
to validate)
Allowed)
Do you have an additional employment activity to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 13b – Employment Activities – Former Federal Service
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
YES NO
Former Federal Service Detail
Branch
Provide dates of federal civilian employment.
From Date (Estimated)
To Date (Estimated/Present)
Provide the name of the federal agency for which you are/were employed.
Name
If Yes to Former
Provide your position title.
Position title (Free Text)
Federal Service
Provide the location of the agency.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
(Multiple Entries
Do you have additional former federal civilian employment, excluding military
YES (Yes adds
NO (Required
Allowed)
service, NOT indicated previously, to report?
another entry)
to validate)

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
DRAFT PRE-DECISIONAL DELIBERATIVE

policy?
YES

NO

Section 14 – Selective Service Record
Were you born a male after December 31, 1959?
YES
NO
Selective Service Registration
Have you registered with the Selective Service System (SSS)?
I don’t know □
YES
NO
The Selective Service website, www.sss.gov, can help provide the registration number for persons who have
Branch
Branch
registered. Note: Selective Service Number is not your Social Security Number
If Yes
Provide registration number:
Registration number (Free Text)
If Yes to Born
You responded 'No' to having registered with the Selective Service System (SSS)
Branch
Male After
If No
Provide explanation
Explanation (Free Text)
12/31/1959
You responded 'I don't know' to having registered with the Selective Service System (SSS)
Branch
If I Don’t Know
Provide explanation
Explanation (Free Text)

Section 15 – Military History

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Have you EVER served in the U.S. Military?
YES NO
You responded ‘Yes’ to having served in the U.S. Military:
Provide the branch of service you served in:
State of service, if National
Officer or enlisted: Provide your service
□ Army □ Army National Guard
Guard
□ Not Applicable
number.
□ Navy □ Air Force □ Air National Guard
□ Officer
Provide your status
□ Marine Corps □ Coast Guard
□ Enlisted
□ Active Duty □ Active Reserve
Number (Free Text)
□ Inactive Reserve
Provide your dates of service.
From Date (Estimated)
To Date (Estimated/Present)
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES NO
You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves
or National Guard.
Branch
Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable
Branch
Conditions □ General □ Bad Conduct □ Other (provide type)
If Yes to
Discharged
Provide other discharge type:
Discharge explanation (Free Text)
If Yes to
Provide the date of discharge listed above.
Date/Estimated □
Serving in
Branch If Discharge Not Honorable
Provide the reason(s) for the discharge.
Reason(s) (Free Text)
the U.S.
Do
you
have
additional
military
service
to
report?
YES
(Yes
adds
another
entry)
NO (Required to validate)
Military
In the last 7 years, have you been subject to court martial or other disciplinary procedure under the Uniform Code
YES NO
of
Military
Justice
(UCMJ),
such
as
Article
15,
Captain’s
mast,
Article
135
Court
of
Inquiry,
etc?
(Multiple
You responded ‘Yes’ to having been subject to court martial or other disciplinary procedure under the Uniform Code
Entries
of Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc. in the last 7 years.
Allowed)
Provide the date of the court martial or other disciplinary procedure.
Date (Estimated)
Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you
Description
were charged.
(Free Text)
Branch
Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast,
Name
If Yes to
Article 135 Court of Inquiry, etc.
(Free Text)
Military
Provide the description of the military court or other authority in which you were charged (title of
Description
Discipline
court or convening authority, address, to include city and state or country if overseas).
(Free Text)
Provide the description of the final outcome of the disciplinary procedure, such as found guilty,
Description
found not guilty, fine, reduction in rank, imprisonment, etc.
(Free Text)
In the last 7 years do you have an additional
YES (Yes adds another entry)
NO (Required to validate)
instance of military discipline to report?
Have you EVER served, as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces,
YES NO
militia, other defense force, or government agency?
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.
During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc.), Specify
□ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government
Agency, Specify
Provide the name of the foreign organization.
Name (Free Text)
Provide your period of service.
From Date (Estimated)
To Date (Estimated/Present)
Branch
Provide the name of the country.
Provide your highest position/rank held
Position held (Free Text)
Provide the division/department/office in which you served.
Division (Free Text)
If Yes to
Provide a description of the circumstances of your association with this organization.
Description (Free Text)
Serving in a
Provide a description of the reason for leaving this service.
Description (Free Text)
Foreign
Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this
YES NO
Military
organization?
You responded ‘Yes’ to maintaining contact with current or former associates, colleagues, acquaintances from your
(Multiple
service in this organization; provide full name, address (if known), official title, length of association, and frequency
Entries
Branch
of contact for each former associate, colleague or acquaintance with whom you maintain contact.
Allowed)
Provide the contact’s full name.
Last name:
First name:
Middle name:
Suffix
If Yes to
Provide the contact’s address.
Street address
City
Maintain
Provide Country if outside the United States; otherwise, provide
State
Zip Code
Country
Contact
State and Zip Code.
Provide the contact’s official title.
Official title (Free Text)
(Multiple
Provide
the
length
of
your
association
with
the
contact.
From
Date
(Estimated)
To Date (Estimated/Present)
Entries
Provide the frequency of contact.
Frequency (Free Text)
Allowed)
Do you have an additional foreign military
YES (Yes adds another entry)
NO (Required to validate)
service contacts to report?
Do you have an additional foreign military service to report?
YES (Yes adds another entry)
NO (Required to validate)
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Section 16 – People Who Know You Well

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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.
(Multiple Entries Allowed)
Provide dates known.
From Date
To Date (Estimated/Present)
Provide full name
Last
First
Middle
Suffix
(Estimated)
name:
name:
name:
Provide rank/title.
Rank/title (Free Text) Provide relationship to you: (Check all that apply) □ Neighbor □ Friend
Explanation
□ Not applicable
□ Work associate □ Schoolmate □ Other (Provide explanation)
(Free Text)
Provide phone number for this person.
□ I don’t know
Telephone/Extensi
on Time Day
Night Both
_Check box if
International or
DSN phone
number
Provide mobile/cell phone number for this person. □ I don’t know
Telephone/Ext
ension Time Day
Night Both
_Check box if
International or
DSN phone
number
Provide e-mail address for this person.
□ I don’t know
Email (Free Text)
Provide home or work address for this person.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Do you have an additional person who knows you well to list?
YES (Yes adds another entry)
NO (Required to validate)

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Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic
partnership: □ Never entered into a civil marriage, legally recognized civil union, or legally recognized domestic partnership □Currently in a legally
recognized domestic partnership or legally recognized civil union □ Separated □ Annulled □ Divorced/Dissolved □ Widowed
You selected “Currently in a civil marriage,” “currently in a legally recognized civil union or legally recognized domestic
partnership” or “Separated.” Complete the following about the person with whom you are in a civil marriage, legally recognized civil
union, or legally recognized domestic partnership, or the person from whom you are currently separated.
Provide full name.
Last
First
Middle
Suffix
Provide date of birth.
Date (Est.)
name:
name: name:
Provide place of birth.
City
County
State or Country
If the person is foreign born, provide one type of documentation that he or she possesses and the document number.
Born Abroad to U.S. Parents:
□ FS 240 or 545
□ DS 1350
Naturalized:
__Alien Registration (on Certificate of Naturalization—utilize USCIS, CIS, or INS Registration number)
__Permanent Resident Card (I-551)
__Certificate of Naturalization (N550 or N570)
Derived:
__Alien Registration (on Certificate of Citizenship—utilize USCIS, CIS, or INS Registration number)
Branch
__Permanent Resident Card (I-551)
Branch
__Certificate of Citizenship (N560 or N561)
If the person
If In A
Not a U.S. Citizen:
is Foreign
Marriage,
__I-551 Permanent Resident
Born
Civil
__I-766 Employment Authorization
Union, or
__I-94 Arrival-Departure Record
Domestic
__U.S. Visa (red foil number)
Partnership
__I-20 Certificate of Eligibility for Non-Immigrant-F1-Student
or
__DS-2019 Certificate of Eligibility of Exchange Visitor-J1-Status
Separated
□ Other (Provide explanation)
Explanation (Free Text)
Provide document number
Number (Free Text)
Provide document expiration
Date of expiration
date, if applicable.
_ _-_ _-_ _ _ _
Estimated __
Provide U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _
Provide other names used (such as maiden name, names by other marriages, civil
Last name:
First name:
Middle name:
marriages, legally recognized civil unions, or legally recognized domestic
Suffix
□ Maiden Name
partnerships, nicknames, etc., and provide dates used for each name).
□ Not applicable
Dates Used
From Date (Estimated)
To Date (Estimated/Present)
Provide country(ies) of Citizenship.
Provide date when you
Date (Estimated)
entered into your civil
marriage, civil union, or
domestic partnership.
Provide location.
City
County
State or Country
Provide current address, if different than your current address.
Street address and City
□ Use my current address.
State and Zip Code or Country
Provide telephone number. □ Use my current telephone number
Number/Ext Extension Time
Day Night Both _Check box if
International or DSN phone
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number
Provide email address
Email (Free Text)
Does the person have an APO/FPO address?
YES NO
Branch APO/FPO
Address
APO/FPO
APO State Code
Zip
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter.
Physical
Provide physical location
Street Address/unit/duty location City/Post Name
State Zip
Country
Location
data:
Are you separated?
YES NO
Provide date of separation.
Date (Estimated)
Branch
If legally separated, provide the location of the record. □ Not Applicable
If Separated
City
State and Zip Code or Country
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?
YES NO
Provide information about any person from whom you are divorced/dissolved, annulled, or widowed.
Provide the full name.
Last name:
First name:
Middle
Suffix
name:
Provide the date of birth.
Date (Estimated
Branch
Provide the place of birth.
City
State
Country
Provide the country(ies) of citizenship.
Country
If
Provide the telephone number.
□ I don’t know
Widowed,
Provide the date your civil marriage, civil union, or domestic partnership was legally recognized.
Date (Estimated)
Divorced/
Provide the location.
City
State or Country
Provide the date divorced/dissolved, annulled or
Date (Estimated)
Dissolved,
widowed
or Annulled
Provide the status.
□ Divorced/Dissolved □ Widowed □ Annulled
Provide
where
the
record
of
divorce/dissolution
or
annulment
is located.
City
State and Zip Code or
Branch
(Multiple
Country
If
Entries
Is this person deceased?
I don’t know
YES NO
Divorced/Di
Allowed)
ssolved or
Provide last known address of the person from whom you
Street and City
Branch If Not
Annulled
are divorced/dissolved or annulled.
□ I don’t know
Deceased
State and Zip Code or Country
Do you have any additional person(s) from whom you are
YES
NO
divorced/dissolved, annulled, or widowed to report?
(Yes adds another entry)
(Required to validate)
Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic partner, with whom you share
YES NO
bonds of affection, obligation, or other commitment, as opposed to a person with whom you live for reasons of convenience (e.g. a
roommate)? If so, complete the following. If the person was born outside the U.S., provide citizenship information.
You have indicated that you currently have a cohabitant.
Provide the cohabitant full name.
Last name:
First name:
Middle
Suffix
name:
Provide the date of birth.
Date (Estimated)
Provide the place of birth.
City
State
Country
For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document
number.
Born Abroad to U.S. Parents:
□ FS 240 or 545
□ DS 1350
Naturalized:
__Alien Registration (on Certificate of Naturalization—utilize USCIS, CIS, or INS Registration number)
__Permanent Resident Card (I-551)
__Certificate of Naturalization (N550 or N570)
Derived:
__Alien Registration (on Certificate of Citizenship—utilize USCIS, CIS, or INS Registration number)
Branch
Branch If
__Permanent Resident Card (I-551)
Cohabitant
__Certificate of Citizenship (N560 or N561)
If Yes to
is Foreign
Not a U.S. Citizen:
Residing
Born
__I-551 Permanent Resident
With a
__I-766 Employment Authorization
Cohabitant
__I-94 Arrival-Departure Record
(Multiple
__U.S. Visa (red foil number)
Entries
__I-20 Certificate of Eligibility for Non-Immigrant-F1-Student
Allowed)
__DS-2019 Certificate of Eligibility of Exchange Visitor-J1-Status
□ Other (Provide explanation)
Explanation (Free Text)
Provide document number
Number (Free Text)
Provide document expiration
Date of expiration
date, if applicable.
_ _-_ _-_ _ _ _
Estimated __
Provide your cohabitant’s U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _
Provide other names used by your cohabitant (such as maiden name, names by
Last name:
First name:
Middle
other marriages, etc., and provide dates each name was used) □ Not applicable
name:
Suffix
□ Maiden Name
Dates Used
From Date (Estimated)
To Date (Estimated/Present)
Provide your cohabitant’s country(ies) of Citizenship.
Provide date cohabitation
Date (Estimated)
residing with person began.
Do you have an additional cohabitant to report?
YES (Yes adds another entry)
NO (Required to validate)

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.) 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
Provide relative type. (Multiple Entries Allowed)
□ Mother □ Father □ Stepmother □ Stepfather □ Foster parent □ Child (including adopted/foster) □ Stepchild □ Brother □ Sister □ Stepbrother
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□ Stepsister □ Half-brother □ Half-sister □ Father-in-law □ Mother-in-law □ Guardian
Provide your relative’s full name.
Last
First
Middle
Suffix
Provide your relative’s date of birth.
Date/Estimated □
name:
name:
name:
Provide your relative’s place of birth. City
State
Country
Provide your relatives country(ies) of citizenship.
Branch - If Mother
Provide your mother’s maiden name. (□ same as listed)
Last name:
First name:
Middle
Suffix
name:
Relatives other names used.
Branch
Has this relative used any other names?
YES NO
If Father, Mother,
Provide other names used and the period of time that your relative used them (such as maiden, name by a
Branch
Child, Stepchild,
If Other
former marriage, former name, alias, or nickname).
Brother, Sister,
Names
Last
First
Middle
Suffix
Maiden name?
YES NO
Half-Brother, Half(Multiple
name:
name:
name:
Sister, Step-Brother,
Entries
From Date
To Date
Provide the reason(s) why the name
Reason
Step-Sister, StepAllowed)
(Estimated)
(Estimated/Present)
changed.
(Free Text)
Mother, Step-Father
Has this relative used any additional names? YES (Yes adds another entry)
NO (Required to validate)
Is your relative deceased?
YES NO
Provide your relative’s current address.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Branch
If Not Deceased
Does this relative have an APO/FPO address?
I don’t know
YES NO
Branch If APO/FPO Provide your relative’s APO/FPO address
Address
APO/FPO
APO/FPO State Zip
U.S. Citizenship Documentation
Provide one type of citizenship documentation and document number below:
Explanation
Branch
Born Abroad to U.S. Parents:
(Free Text)
If Father, Mother, Child, Stepchild, Brother,
□ FS 240 or 545
Sister, Half-Brother, Half-Sister, Step-Brother,
□ DS 1350
Step-Sister, Step-Mother, Step-Father
Naturalized:
AND Relative is U.S. Citizen
__Alien Registration (on Certificate of Naturalization—utilize USCIS, CIS, or
AND Relative POB is Foreign
INS Registration number)
AND Relative is Deceased
__Permanent Resident Card (I-551)
--- OR --__Certificate of Naturalization (N550 or N570)
Relative Current Address is in U.S.
Derived:
AND Relative POB is Foreign
__Alien Registration (on Certificate of Citizenship--utilize USCIS, CIS, or INS
AND Relative is U.S. Citizen
Registration number)
--- OR --__Permanent Resident Card (I-551)
Relative has APO/FPO Address
__Certificate of Citizenship (N560 or N561)
AND Relative POB is Foreign
□ Other (Provide explanation)
AND Relative is U.S. Citizen
Provide the document number.
Number (Free Text)
--- OR --Provide the name of the court that issued the Certificate of Naturalization.
Relative POB is Foreign
Court Name (Free Text)
AND Relative is U.S. Citizen
Provide the address of the court that issued the Certificate of Naturalization.
Street address
City
State
Zip Code
Provide type of documentation he or she possesses to support U.S. Explanation (Free Text)
residence:
Not a U.S. Citizen:
__I-551 Permanent Resident
__I-766 Employment Authorization
Branch
__I-94 Arrival-Departure Record
If Relative has
__U.S. Visa (red foil number)
U.S. Address
__I-20 Certificate of Eligibility for Non-Immigrant-F1-Student
__DS-2019 Certificate of Eligibility of Exchange Visitor-J1-Status
□ Other (Provide explanation)
Provide the document number.
Document Number (Free Text)
Provide document expiration date.
Expiration date. _ _-_ _-_ _ _ _
Branch
Estimated__
Provide approximate date of first contact.
Date/Estimated □
If Relative does not
Provide approximate date of last contact.
Date/Estimated □
have U.S.
Provide methods of contact (check all that apply) □ In person
Explanation
Citizenship
Branch
□ Telephone □ Electronic (Such as e-mail, texting, chat rooms,
(Free Text)
AND
If Relative has
etc.) □ Written correspondence □ Other (Provide explanation)
Relative is Not
Foreign Address
Deceased
Provide Approximate frequency of contact □ Daily □ Weekly
Explanation (Free Text)
□ Monthly □ Quarterly □ Annually □ Other (Provide
explanation)
Provide name of current employer, or provide the name of their most recent employer if
Employer Name (Free Text)
not currently employed (if known). □ I don’t know
Provide the address of current employer, or provide the address of their most recent
Street address
City
employer if not currently employed. □ I don’t know
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Is this relative affiliated with a foreign government, military, security, defense industry,
I don't know
YES NO
foreign movement, or intelligence service?
Branch - If Relative has
Describe the relative’s relationship with the foreign government, military,
Description
Foreign Affiliation
security, defense industry, foreign movement, or intelligence service.
(Free Text)
Do you have an additional relative to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 19 – Foreign Contacts
A foreign national is defined as any person who is not a citizen or national of the U.S.
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 legally recognized civil union/domestic partner, or cohabitant are bound by affection, influence, common
DRAFT PRE-DECISIONAL DELIBERATIVE

YES

NO

interests, and/or obligation? Include associates as well as relatives, not previously listed in Section 18.
You indicated that you have, or have had, close and/or continuing contact with a foreign national.
Provide the full name of the foreign national, if known □ I don’t know Last name:
First name:

Explanation if name is unknown.
Explanation (Free Text)
Provide approximate date of first contact. Date/Estimated □
Provide approximate date of last contact.
Date/Estimated □
Provide methods of contact (check all that apply) □ In person □ Telephone □ Electronic (Such as e-mail,
Explanation
texting, chat rooms, etc) □ Written correspondence □ Other (Provide explanation)
(Free Text)
Provide approximate frequency of contact. □ Daily □ Weekly □ Monthly □ Quarterly □ Annually
Explanation
□ Other (Provide explanation)
(Free Text)
Provide the nature of relationship (select all that apply)
Explanation
□ Professional or Business □ Personal (Such as family ties, friendship, affection, common interests, etc)
(Free Text)
□ Obligation (Provide explanation) □ Other (Provide explanation)
Provide other names and/or nicknames, as appropriate.
Last name:
First name:
Middle
Suffix
name:
Provide country(ies) of citizenship.
Country
Provide date of birth □ I don’t know
Date/Estimated □
Provide place of birth.
□ I don’t know
City
Country
Provide current address. □ I don’t know
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Does this person have an APO/FPO address? □ Yes □ No □ I don’t know
Branch APO/FPO Provide the foreign national’s APO/FPO address.
Address
APO/FPO
APO/FPO State Zip
Provide the name of the foreign national’s current employer, or provide the name of their most recent
Employer Name
employer if not currently employed. □ I don’t know
(Free Text)
Provide the address of the foreign national’s current employer, or provide the address
Street address
City
of their most recent employer if not currently employed. □ I don’t know
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?
□ Yes □ No □ I don't know
Branch Contact
Describe the contact’s relationship with the foreign government,
Description (Free Text)
Foreign Military
military, security, defense industry, or intelligence service.
Do you have, or have you had, close and/or continuing contact with any additional foreign
YES
NO
national within the last seven (7) years with whom you, or your spouse, or cohabitant are
(Yes adds
(Required to
bound by affection, influence, common interests, and/or obligation? Include associates as well
another entry)
validate)
as relatives, not previously listed in Section 18.

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(Multiple
Entries
Allowed)

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Branch
If Yes to
having contact
with a Foreign
National

Middle
name:

Section 20a – Foreign Activities

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Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children EVER had any foreign
YES NO
financial interests (such as stocks, property, investments, bank accounts, ownership of corporate entities, corporate interests or
exchange traded funds (ETFs) held in specific geographical or economic sectors) in which you or they have direct control or direct
ownership? (Exclude financial interests in companies or diversified mutual funds or diversified ETFs that are publicly traded on a
U.S. exchange.)
You responded ‘Yes’ to you, your spouse or legally recognized civil union/domestic partner, 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 exchange traded funds (ETFs) held in specific
geographical or economic sectors) in which you or they have direct control or direct ownership (Exclude financial interests in
companies or diversified mutual funds or diversified ETFs that are publicly traded on a U.S. exchange.)
Specify: (check all that apply) □ Yourself □ Spouse or legally recognized civil union/domestic partner □ Cohabitant
□ Dependent children
Provide the type of financial interest.
Type (Free Text)
Provide the date acquired
Date (Estimated)
Provide how the financial interest was
How Acquired
Provide the cost (in U.S. dollars) at
Cost (Free Text)
Branch
acquired (such as purchase, gift, etc.)
(Free Text)
time of acquisition. □ Estimated
Provide the current value (in U.S. dollars) or the value at the time control or
Value (free Text)
If Yes to
ownership was sold, lost or otherwise disposed of. □ Estimated
Having
Provide the date control or ownership
Date
Provide explanation of how interest control or
Explanation
Foreign
was relinquished. □ Not applicable:
(Estimated)
ownership was sold, lost or otherwise disposed of.
(Free Text)
Financial
Are there any co-owners of this foreign financial interest?
YES NO
Interests
You responded ‘Yes’ to there being co-owners; provide the name, address, citizenship, and relationship of the
co-owner(s).
(Multiple
Branch
Provide full name of co-owner.
Last name:
First name:
Middle name:
Suffix
Entries
If Yes to
Provide
co-owner
current
address.
Street
address
City
Allowed)
Having CoProvide Country if outside the United States; otherwise, provide State
State
Zip Code
Country
Owners
and Zip Code.
(Multiple
Provide co-owner’s country(ies) of citizenship.
Country
Entries
Provide the nature of your relationship with the co-owner.
Nature of relationship (Free Text)
Allowed)
Are there any additional co-owners of this foreign
YES
NO
financial interest?
(Yes adds another entry) (Required to validate)
Do you, your spouse or legally recognized civil union/domestic partner,
YES
NO
cohabitant, or dependent children have any additional foreign financial
(Yes adds another entry) (Required to validate)
interests?
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children EVER had any foreign
YES NO
financial interests that someone controlled on your behalf?
You responded ‘Yes’ to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
having EVER had any foreign financial interests that someone controlled on your behalf.
Specify: (check all that apply) □ Yourself □ Spouse or legally recognized civil union/domestic partner □ Cohabitant □
Dependent children
Branch
Provide the type of financial interest.
Type (Free Text)
Provide the name of the individual who controls this financial interest on your behalf.
Last name:
First name:
DRAFT PRE-DECISIONAL DELIBERATIVE

Provide this individual’s relationship to you.
Relationship (Free Text)
Provide the date the financial interest was acquired.
Date (Estimated)
Provide the cost (in U.S. dollars) at time of acquisition. □ Estimated
Cost (Free Text)
Provide details regarding how it was acquired (such as purchase, gift, etc.).
How acquired (Free Text)
Provide the current value (in U.S. dollars) or value at the time interest was sold, lost or
Value (Free Text)
otherwise disposed of. □ Estimated
Provide the date interest was sold, lost, or otherwise disposed of. □ Not applicable
Date (Estimated)
Provide explanation if interest was sold, lost, or otherwise disposed of.
Explanation (Free Text)
(Multiple
Are there any co-owners of the foreign financial interest controlled on your behalf?
YES NO
Entries
You responded ‘Yes’ to there being any co-owners.
Branch
Allowed)
If Yes to
Provide full name of co-owner.
Last name:
First name:
Middle name: Suffix
Having CoProvide the current address of the co-owner.
Street address
City
Owners
Provide Country if outside the United States; otherwise, provide State
State
Zip Code
Country
(Multiple
and Zip Code.
Entries
Provide co-owner’s country(ies) of citizenship.
Country
Allowed)
Provide the nature of your relationship with the co-owner.
Relationship (Free Text)
Are there any additional co-owners for this foreign
YES
NO
financial interest controlled on your behalf to report?
(Yes adds another entry) (Required to validate)
Do you, your spouse or legally recognized civil union/domestic partner,
YES
NO
cohabitant, or dependent children have any additional foreign financial
(Yes adds another entry) (Required to validate)
interests controlled on your behalf?
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children EVER owned, or do
YES NO
you anticipate owning, or plan to purchase real estate in a foreign country?
You responded ‘yes’ to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
having ever owned, or anticipate owning, or planning to purchase real estate in a foreign country.
Specify: (check all that apply) □ Yourself □ Spouse or legally recognized civil union/domestic partner □ Cohabitant
□ Dependent children
Branch
Provide the type of real estate property (such as home, business, etc.).
Real estate type (Free Text)
Provide the location/address of property.
Street
City
Country
If Yes to
Provide the date of purchase or to be acquired.
Date (Estimated)
Having
Provide how the foreign real estate was or is to be acquired (such as purchase, gift,
How acquired (Free Text)
Foreign Real
etc.).
Estate
Provide the date sold, if applicable.
Date (Estimated)
Provide the cost (in U.S. dollars) when sold or expected at time of acquisition.
Cost (Free Text)
(Multiple
□ Estimated
Entries
Are/were/will there any co-owners of this foreign real estate?
YES NO
Allowed)
You responded ‘Yes’ to there being any co-owners.
Branch
If Yes to
Provide full name of co-owner.
Last name:
First name:
Middle name:
Suffix
Having CoProvide co-owner current address.
Street address
City
Owners
Provide Country if outside the United States; otherwise, provide State
State
Zip Code
Country
(Multiple
and Zip Code.
Entries
Provide co-owner’s country(ies) of citizenship.
Allowed)
Provide the nature of your relationship with the co-owner.
Nature of relationship (Free Text)
Are there any additional co-owners of this foreign real
YES
NO
estate?
(Yes adds another entry) (Required to validate)
Do you have an additional instance of you, your spouse or legally recognized
YES
NO
civil union/domestic partner, cohabitant, or dependent children EVER having (Yes adds another entry) (Required to validate)
owned, or anticipate owning, or planning to purchase real estate in a foreign
country?
As a U.S. citizen, have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
YES NO
received in the last 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?
You responded ‘Yes’ that as a U.S. citizen, have you, your spouse or legally recognized civil union/domestic partner, cohabitant,
or dependent children received in the last 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;
Specify: (check all that apply) □ Yourself □ Spouse or legally recognized civil union/domestic partner □ Cohabitant
□ Dependent children
Provide the type of benefit. Educational, Medical, Retirement
Provide the frequency of the benefit. Onetime benefit,
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Social Welfare, Other such benefit (Provide explanation)
Future benefit, Continuing benefit, Other (Provide explanation)
Explanation (Free Text)
Explanation (Free Text)
If Yes to
You have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or
Having
dependent children received a onetime benefit from a foreign country
Foreign
Provide the date the benefit was received.
Date (Estimated)
Benefit
Provide the name of the country providing the benefit.
Country
Branch
If Onetime
Provide the total value (in U.S. dollars) of the benefit received. □ Estimated
Value (Free Text)
(Multiple
Benefit
Provide the reason this benefit was received.
Reason (Free Text)
Entries
As a result of this benefit are you, your spouse or legally recognized civil
YES
NO
Allowed)
union/domestic partner, your cohabitant, or dependent children obligated in any
Explanation (Free Text)
way to this foreign country? If yes provide explanation
You have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or
dependent children expect to receive a benefit from a foreign country.
Provide the date the benefit will begin.
Date (Estimated)
Branch
If Future
Provide the frequency the benefit will be received.
Explanation (Free Text)
Benefit
Annually
Quarterly
Monthly
Weekly Other (Provide explanation)
Provide the name of the country providing this benefit.
Country
Provide the value (in U.S. dollars) of the benefit to be received. □ Estimated
Value (Free Text)
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If Yes to
Having
Foreign
Financial
Interests
Controlled on
Your Behalf

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Provide the reason this benefit will be received.
Reason (Free Text)
As a result of this benefit are you, your spouse or legally recognized civil
YES
NO
union/domestic partner, your cohabitant, or dependent children obligated in any
Explanation (Free Text)
way to this foreign country? If yes provide explanation.
You have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or
dependent children receive a continuing or other benefit from a foreign country.
Provide the date the benefit began.
Date (Estimated)
Provide the date the benefit is expected to end.
Date (Estimated)
Provide the frequency that this benefit is received.
Explanation (Free Text)
Branch
Annually Quarterly Monthly
Weekly
Other (Provide explanation)
If Continuing
Provide the name of the country providing this benefit.
Country
Benefit
Provide the total value (in U.S. dollars) of the benefit to be received. □ Estimated
Value (Free Text)
Provide the reason this benefit will be received.
Reason (Free Text)
As a result of this benefit are you, your spouse or legally recognized civil
YES
NO
union/domestic partner, your cohabitant, or dependent children obligated in any
Explanation (Free Text)
way to this foreign country? If yes provide explanation.
Do you, your spouse or legally recognized civil union/domestic partner,
YES
NO
cohabitant, or dependent children receive any additional benefits from a
(Yes adds another entry) (Required to validate)
foreign country?
Have you EVER provided financial support for any foreign national?
YES NO
You responded ‘Yes’ to providing financial support for any foreign national.
Branch
If Yes to
Provide the name of the foreign national you support or have supported financially.
Last
First
Middle
Suffix
Foreign
name:
name:
name:
National
Provide the address of the foreign national listed above.
Street address
City
Support
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip
Country
(Multiple
Code
Entries
Provide the nature of your relationship with the foreign national listed above.
Nature of relationship (Free Text)
Allowed)
Provide the amount (in U.S. dollars) of all financial support provided. □ Estimated
Amount (Free Text)
Provide the frequency of your support. Frequency (Free Text)
Provide this foreign national’s country(ies) of citizenship.
Have you additionally provided financial support for any foreign national?
YES
NO
(Yes adds another entry) (Required to validate)

Section 20b – Foreign Business, Professional Activities, and Foreign Government Contacts

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Have you in the last seven (7) years provided advice or support to any individual associated with a foreign business or other foreign YES NO
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.)
You responded ‘Yes’ to having in the last 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.
Provide a description of advice/support provided.
Description (Free Text)
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Provide the name of the individual to whom advice or support was provided. Last name: First
Middle
Suffix
name:
name:
If Yes to
Provide the name of the foreign organization or foreign business with whom the individual is associated.
Advice or
Provide the country of origin for the organization or business.
Support
Provide the date(s) during which this advice or support was provided. From date (Estimated)
To date
(Estimated/Present)
(Multiple
Describe what compensation, if any, was provided for your service.
Compensation (Free Text)
Entries
Have you in the last seven (7) years provided advice or support to any other individual
YES
NO
Allowed)
associated with a foreign business or other foreign organization that you have not previously
(Yes adds
(Required to
listed as a former employer? (Answer “No” if all your advice or support was authorized
another entry)
validate)
pursuant to official U.S. Government business.)
For this question, “Immediate Family” means your spouse or legally recognized civil union/domestic partner, parents, step-parents,
YES NO
siblings, half and step-siblings, children, step-children, and cohabitant. Have you, your spouse or legally recognized civil
union/domestic partner, cohabitant, or any member of your immediate family in the last 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.)
You responded ‘Yes’ to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or any member of your
immediate family having in the last seven (7) years been asked to provide advice or serve as a consultant, even informally, by any
foreign government official or agency.
Branch
Provide the name of the government official.
Last name:
First name:
Middle name:
Suffix
If Yes to
Provide the name of the agency.
Agency name (Free Text)
Foreign
Provide the country with which the government official or agency is affiliated.
Consulting
Provide the date of the request.
Date (Estimated)
Provide the circumstances of request.
Circumstances (Free Text)
(Multiple
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or any
YES
NO
Entries
member of your immediate family in the last seven (7) years been asked to provide advice or
(Yes adds
(Required to
Allowed)
serve as a consultant, even informally, by any other foreign government official or agency?
another
validate)
(Answer ‘No’ if all the advice or support was authorized pursuant to official U.S. Government
entry)
business.)
Has any foreign national in the last seven (7) years offered you a job, asked you to work as a consultant, or consider employment
YES NO
with them?
You responded ‘Yes’ to any foreign national having in the last seven (7) years offered you a job, asked you to work as a
consultant, or consider employment with them.
Branch
Provide the name of the foreign national who made the offer. Last name:
First name:
Middle name: First
If Yes to
Provide a description of the position offered.
Description (Free Text)
Offered Job
(Multiple
Provide the date when this offer was extended.
Date (Estimated)
Entries
Provide the location where this occurred.
City
State and Zip Code or Country
Allowed)
Did you accept the offer?
Explanation (Free Text)
YES NO
Has any additional foreign national,
the last seven (7) years,
offered you
YES
NO
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a job, asked you to work as a consultant, or consider employment with
(Yes adds another entry)
(Required to validate)
them?
Have you in the last seven (7) years been involved in any other type of business venture with a foreign national not described above YES NO
(own, co-own, serve as business consultant, provide financial support, etc.)?
You responded ‘Yes’ to having in the last seven (7) years been involved in any other type of business venture with a foreign
national not described above.
Provide the full name of this foreign national.
Last name:
First name:
Middle name:
Suffix
Provide the full current address of this foreign national.
Street address
City
Branch
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Provide a description of the business venture.
Description (Free Text)
If Yes to Other Provide the citizenship(s) of this foreign national.
Provide your relationship to this foreign national.
Relationship (Free Text)
Foreign
Business
Provide the length of time you have been involved in the
From Date (Estimated)
To Date (Estimated/Present)
Ventures
business venture.
Provide the nature of association with this business venture.
Nature of association (Free Text)
(Multiple
Provide the position you held.
Position (Free Text)
Entries
Provide the service you provided.
Service (Free Text)
Provide the financial support involved.
Support (Free Text)
Allowed)
Provide a description of what compensation was provided for your service.
Description of compensation (Free Text)
Have you, in the last seven (7) years, been involved in any other type of business venture
YES
NO
with a foreign national not described above (own, co-own, serve as business consultant,
(Yes adds
(Required to
provide financial support, etc.)?
another entry)
validate)
Have you in the last seven (7) years attended or participated in any conferences, trade shows, seminars, or meetings outside the
YES NO
U.S.? (Do not include those you attended or participated in on official business for the U.S. government.)
You responded ‘Yes’ to in the last seven (7) years having attended or participated in any conferences, trade shows, seminars, or
meetings outside the U.S.
Provide the name and description of event.
Name and description (Free Text)
Provide the name of sponsoring organization.
Organization name (Free Text)
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Provide the city where the event was held.
City (Free Text) Provide the country where the event was held.
Country
If Yes to
Provide the dates for the event.
From Date (Estimated)
To Date (Estimated/Present)
Attending
Provide the purpose of the event.
Purpose (Free Text)
Foreign
Was there any subsequent contact with any foreign nationals as a result of the event?
YES NO
Conferences
You responded ‘Yes’ to there having been subsequent contact with any foreign nationals as a result of the
Branch
event.
If Yes to Subsequent
(Multiple
Contact
Provide explanation.
Explanation (Free Text)
Entries
(Multiple Entries
Do you have another subsequent contact to report YES
NO
Allowed)
Allowed)
for this event?
(Yes adds another entry) (Required to validate)
Have you in the last seven (7) years, attended or participated in any additional conferences,
YES
NO
trade show, seminars, or meetings outside the U.S.? (Do not include those you attended or
(Yes adds
(Required to
participated in on official business for the U.S. government).
another entry)
validate)
For Section 20b, “Immediate Family” means your spouse, parents, step-parents, siblings, half and step-siblings, children, stepYES NO
children, and cohabitant. Have you or any member of your immediate family in the last 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, foreign travel on a U.S. passport, or as a U.S. military service member in
conjunction with a U.S. Government military duty.)
You responded ‘Yes’ to you or any member of your immediate family having in the last 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.
Provide the name of the individual involved in the contact.
Last name:
First name:
Middle name:
Suffix
Provide the location of the contact.
City
State and Zip Code or
Country
Provide the date of contact.
Date (Estimated)
Provide the foreign government(s) involved.
Provide the type of establishment (such as embassy, consulate, agency, military service,
Establishment type (Free Text)
intelligence or security service, etc.) involved.
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Provide the names of the foreign representatives involved in contact.
Foreign representatives (Free Text)
Provide the purpose/circumstances of contact.
Purpose/circumstances (Free Text)
If Yes to
Foreign
Was there any subsequent contact initiated by you, your immediate family member, or a representative of the
YES NO
Government
foreign organization?
Contact
You responded ‘Yes’ to there having been subsequent contact initiated by you, your immediate family
Branch
member, or a representative of the foreign organization.
(Multiple
Provide the purpose of the subsequent contact.
Purpose (Free Text)
If Yes to Subsequent
Entries
Contact
Provide the date of most recent contact.
Date (Estimated)
Allowed)
Provide plans for future contact.
Plans (Free Text)
(Multiple Entries
Do you have another subsequent contact to report YES
NO
Allowed)
for this event?
(Yes adds another entry) (Required to validate)
Have you or any member of your immediate family in the last seven (7) years had any additional
YES
NO
contact with a foreign government, its establishment (such as embassy, consulate, agency, military
(Yes adds
(Required to
service, intelligence or security service, etc.) or its representatives, whether inside or outside the
another
validate)
U.S.? (Answer ‘No’ if the contact was for routine visa applications and border crossings related to
entry)
either official U.S. Government travel, foreign travel on a U.S. passport, or as a U.S. military
service member in conjunction with a U.S. Government military duty.)
Have you in the last seven (7) years sponsored any foreign national to come to the U.S. as a student, for work, or for permanent
YES NO
residence?
You responded ‘Yes’ to in the last seven (7) years having sponsored any foreign national to come to the U.S. as a student, for
Branch
work, or for permanent residence.
If Yes to
Last name:
First name:
Middle name:
Suffix
Sponsorship of Provide the name of the sponsored foreign national.
a Foreign
Provide the date of birth for the sponsored foreign national. □ I don’t know
Date (Estimated)
National
Provide the place of birth for the sponsored foreign national.
City
State and Zip Code or Country
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Provide the current street address of the sponsored foreign
Street address and city
State and Zip Code or Country
national.
Provide the country(ies) of citizenship for the sponsored foreign national.
Provide the name of the organization through which sponsorship was arranged, if
Name (Free Text)
applicable. Not Applicable □
Provide the address of the organization through which sponsorship was arranged, if applicable. Not Applicable □
Street address and city
State and Zip Code
Provide the dates of stay in the U.S. for the sponsored foreign national.
From date (Estimated)
To date
(Estimated/Present)
Provide the address of the sponsored foreign national while residing in the U.S.
Street address and city
State and Zip Code
Provide the purpose of stay in the U.S. for the sponsored foreign national.
Purpose of stay (Free Text)
Provide the purpose of your sponsorship for the sponsored foreign national.
Purpose of sponsorship (Free Text)
Have you in the last seven (7) years sponsored any additional foreign national to come to
YES
NO
the U.S. as a student, for work, or for permanent residence?
(Yes adds
(Required to
another entry)
validate)
Have you EVER held political office in a foreign country?
YES NO
You responded ‘Yes’ to having EVER held political office in a foreign country.
Branch
Provide the position held.
Position (Free Text)
If Yes to Held
Provide the dates you held political office.
From Date (Estimated)
To Date (Estimated/Present)
Political
Office
Provide the name of the country involved.
Provide the reason(s) for these activities.
Reasons (Free Text)
(Multiple
Provide your current eligibility to hold political office in a foreign country.
Current eligibility (Free Text)
Entries
Have you EVER held any additional political office in a foreign country?
YES
NO
Allowed)
(Yes adds another entry) (Required to validate)
Have you EVER voted in the election of a foreign country?
YES NO
You responded ‘Yes’ to having EVER voted in the election of a foreign country.
Branch
Provide the date you voted in the foreign election.
Date (Estimated)
If Yes to
Voting in
Provide the name of the country involved.
Provide the reason(s) for these activities.
Reasons (Free Text)
Foreign
Provide your current eligibility to vote in a foreign country.
Current eligibility (Free Text)
Election
Do you have other instances of voting in the election of a foreign country to report?
YES
NO
(Multiple
(Yes adds
(Required to
Entries
another
validate)
Allowed)
entry)

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(Multiple
Entries
Allowed)

Section 20c – Foreign Countries You have Visited

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Have you traveled outside the U.S. in the last past seven (7) years?
YES NO
Has your travel in the last seven (7) years been solely for U.S. Government business/military overseas assignment on official
YES NO
government orders (i.e., no personal trips in conjunction with the official U.S. Government business)?
Your response indicates you have 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 on official government orders.
Provide the country visited.
Provide the dates of your travel to this country. From Date (Estimated)
To Date (Estimated)
Provide the total number of days involved in the visit. □ 1-5 □ 6-10 □ 11-20 □ 21-30 □ More than 30 □ Many short trips
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
Branch
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other
Explanation
YES NO
than for normal customs requirements) by the local customs or security service officials when
(Free Text)
If Yes to
entering or leaving this country? If yes provide explanation.
Having
While traveling to or in this country, were you involved in any encounter with the police? If yes
Explanation
YES NO
Traveled
provide explanation.
(Free Text)
Outside the
While traveling to or in this country, were you contacted by, or in contact with any person known or
Explanation
YES NO
U.S. on
suspected of being involved or associated with foreign intelligence, terrorist, security, or military
(Free Text)
Other than
organizations? If yes provide explanation.
Official
While traveling to, or in this country, were you involved in any counterintelligence or security
Explanation
YES NO
Business
issues not reported? If yes provide explanation.
(Free Text)
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting
Explanation
YES NO
(Multiple
excessive knowledge of or undue interest in you or your job? If yes provide explanation.
(Free Text)
Entries
Allowed)
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to Explanation
YES NO
obtain classified information or unclassified, sensitive information? If yes provide explanation.
(Free Text)
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to
Explanation
YES NO
cooperate with a foreign government official or foreign intelligence or security service? If yes
(Free Text)
provide explanation.
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 on official government orders, but you must include any personal trips
made in conjunction with the official U.S. Government travel).
Do you have additional travel outside the U.S. in the last seven (7)
YES
NO
years for other than solely U.S. Government business on official
(Yes adds another entry)
(Required to validate)
government orders?

Section 21 – Psychological and Emotional Health
The U.S. government recognizes the critical importance of mental health and advocates proactive management of mental health conditions to support
the wellness and recovery of Federal employees and others. Every day individuals with mental health conditions carry out their duties without
presenting a security risk. While most individuals with mental health conditions do not present security risks, there may be times when such a
condition can affect a person’s eligibility for a security clearance.
Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce, major injury, service in a military
combat environment, sexual assault, domestic violence, or other difficult work-related, family, personal, or medical issues may lead to grief,
DRAFT PRE-DECISIONAL DELIBERATIVE

depression, or other responses. The government recognizes that mental health counseling and treatment may provide important support for those who
have experienced such events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage those
who might benefit from such treatment from seeking it.

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Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for
holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to
federally controlled facilities or information systems. Seeking or receiving mental health care for personal wellness and recovery may contribute
favorably to decisions about your eligibility.
21A) Has a court or administrative agency EVER issued an order declaring you mentally
YES
NO (Required to validate)
incompetent?
You responded ‘Yes’ to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Provide the date this occurred.
Date (Month/Year) (Estimated)
Provide the name of the court or administrative agency that declared you mentally
Name (Free Text)
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incompetent.
If Yes to
Provide the address of the court or administrative agency.
Being
Street address and city
State and Zip Code or Country
Declared
Was this matter appealed to a higher court or administrative agency?
YES
NO (Required to validate)
Incompetent
You responded ‘Yes’ to appealed to a higher court or administrative agency.
Branch
(Multiple
If Yes to Appealed to Provide the name of the court or administrative agency.
Name (Free Text)
Entries
a Higher Court or
Provide the address of the court or administrative agency
Allowed)
Administrative
Street address and city
State and Zip Code or Country
Agency. (Multiple
Provide the final disposition.
Disposition (Free Text)
Entries Allowed)
Do you have an additional instance where this matter was appealed to a
YES
NO
higher court or administrative agency?
(Yes adds another entry)
(Required to
validate)
Do you have an additional instance where a court or administrative agency
YES
NO
EVER issued an order declaring you mentally incompetent?
(Yes adds another entry)
(Required to
validate)
21B) Has a court or administrative agency EVER ordered you to consult with a mental health professional (for example, a
YES NO (Required
psychiatrist, psychologist, licensed clinical social worker, etc.)? (An order to a military member by a superior officer is
to validate)
not within the scope of this question, and therefore would not require an affirmative response. An order by a military court
would be within the scope of the question and would require an affirmative response.)
You responded ‘Yes’ to having a court or administrative agency EVER ordered you to consult with a mental health professional.
Branch
If Yes to
Provide the date this occurred.
Date (Month/Year) (Estimated)
Court or
Provide the name of the court or administrative agency that declared you mentally
Name (Free Text)
Administrati
incompetent.
ve agency
Provide the address of the court or administrative agency.
EVER
Street address and city
State and Zip Code or Country
ordered you
Provide the final disposition
Disposition (Free Text)
to consult
Was this matter appealed to a higher court or administrative agency?
YES
NO (Required to validate)
with a mental Branch
You responded ‘Yes’ to appealed to a higher court or administrative agency.
health
If Yes to Appealed
Provide the name of the court or administrative agency.
Name (Free Text)
professional
to a Higher Court or Provide the address of the court or administrative agency
(Multiple
Administrative
Street address and city
State and Zip Code or Country
Entries
Agency. (Multiple Provide the final disposition.
Disposition (Free Text)
Allowed)
Entries Allowed)
Do you have an additional instance where this matter was appealed to a
YES
NO
higher court or administrative agency?
(Yes adds another
(Required to validate)
entry)
Do you have an additional instance where a court or administrative agency
YES
NO
EVER ordered you to consult with a mental health professional (for
(Yes adds another
(Required to validate)
example, a psychiatrist, psychologist, licensed clinical social worker, etc.)?
entry)
(An order to a military member by a superior officer is not within the scope
of this question, and therefore would not require an affirmative response. An
order by a military court would be within the scope of the question and
would require an affirmative response.)
21C) Have you EVER been hospitalized for a mental health condition?
YES
NO (Required to validate)
You responded ‘Yes’ to EVER been hospitalized for a mental health condition.
Branch
If Yes to
Was the admission voluntary or involuntary?
Voluntary (Provide explanation)
Explanation
EVER been
Involuntary (Provide explanation)
Explanation
hospitalized
Provide the dates of treatment.
From Date (Month/Year) (Estimated)
To Date
for a mental
(Month/Year)
health
(Estimated/Present)
condition
Provide the name and address of the facility where treatment was provided.
Name (Free Text)
(Multiple
Provide the address of the facility where treatment was provided.
Entries
Street address and city
State and Zip Code or Country
Allowed)
Do you have an additional instance where you have EVER been hospitalized for a YES (Yes
NO (Required to validate)
mental health condition?
adds another
entry)
The following question asks whether you have been diagnosed with a specified mental health condition that may, particularly if untreated, impact
your judgment, reliability, or trustworthiness. If you answer in the affirmative, we will seek additional information about the seriousness and
symptoms of the condition, as well as any applicable course of treatment. It is important to note that any such diagnosis, in and of itself, is not a
reason to revoke or deny eligibility/or access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain
Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information systems.
21D) Have you EVER been diagnosed by a physician or other health professional (for example, a
YES
NO (Required to
psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic disorder,
validate)
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schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder, borderline
personality disorder, or antisocial personality disorder?
You responded ‘Yes’ to having EVER been diagnosed by a physician or other health professional.
Identify the diagnosis or health condition.
Diagnosis or health condition (Free Text)
Provide the dates of diagnosis.
From Date
To Date
Branch
(Month/Year)
(Month/Year)
If Yes to
(Estimated)
(Estimated/Present)
EVER been
Provide the name, address, and telephone number of the health care professional
Name
Telephone Number
diagnosed by
who diagnosed you, or is currently treating you for such diagnosis, or with
(Free Text)
(Free Text)
a physician
whom you have discussed such condition.
or other
Provide the address of the health care professional who diagnosed you, or is
Street address and city
State and Zip Code
health
currently treating you for such diagnosis, or with whom you have discussed such
or Country
professional
condition.
(Multiple
Provide the name, address, and telephone number of any
Name or same as
Telephone Number
Entries
agency/organization/facility
above (Free Text)
or same as above
Allowed)
where counseling/treatment was provided
(Free Text)
Provide the address of any agency/organization/facility
Street address and city
State and Zip Code
where counseling/treatment was provided
or same as above
or Country or same
as above
Was the counseling/treatment effective in managing your symptoms? Provide
YES
NO
Explanation
explanation.
(Provide
(Free Text)
explanation)
(Required to
validate)
Do you have an additional instance where you EVER had been diagnosed by a
YES (Yes adds
NO (Required to
physician or other health professional (for example, a psychiatrist, psychologist,
another entry)
validate)
licensed clinical social worker, or nurse practitioner) with psychotic disorder,
schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood
disorder, borderline personality disorder, or antisocial personality disorder?
In the last seven years, have there been any occasions when you did not consult
YES
NO (Required to
with a medical professional before altering or discontinuing, or failing to start a
validate)
prescribed course of treatment for any of the listed diagnoses?
Are you currently in treatment?
YES
NO (Required to validate)
Branch
If Yes to
Name
Telephone Number (Free
currently in
Provide the name, address, and telephone number of the
(Free Text)
Text)
treatment.
healthcare professional providing such treatment.
(Multiple
Entries
Provide the address of the healthcare professional providing
Street address and city
State and Zip Code or
Allowed)
such treatment.
Country

Do you have an additional instance where you are currently in
YES (Yes adds
NO (Required to validate)
treatment?
another entry)
21E) Do you have a mental health or other health condition that substantially adversely affects
YES
NO (Required to
your judgment, reliability, or trustworthiness even if you are not experiencing such symptoms
validate)
today?

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Note: If your judgment, reliability, or trustworthiness is not substantially adversely affected by a
mental health or other condition, then you should answer "no" even if you have a mental health or
other condition requiring treatment. For example, if you are in need of emotional or mental health
counseling as a result of service as a first responder, service in a military combat environment,
having been sexually assaulted or a victim of domestic violence, or marital issues, but your
judgment, reliability or trustworthiness is not substantially adversely affected, then answer "no."
You responded ‘Yes’ to having a mental health condition that substantially adversely affects your judgment, reliability, or
Branch
If Yes to
trustworthiness.
having a
Did you ever receive or are you currently receiving counseling
YES
NO
Explanation
I decline to
mental health or treatment for that condition? (You may choose not to answer
(Provide
(Free Text)
answer (Required
condition
this question. However, such consultation or treatment will not
explanation)
to validate)
that
disqualify you and is considered to be a positive action.)
(Required to
adversely
validate)
affects your
Provide the following about your counseling or treatment.
judgment,
Provide the dates of counseling
To Date (Month/Year)
To Date (Month/Year)
reliability, or
Branch
or treatment.
(Estimated)
(Estimated/Present)
trustworthine If Yes to you ever
Provide the name, address, and
Name
Telephone Number (Free Text)
ss.
received or are you
telephone number of the health
(Free Text)
(Multiple
currently receiving
care professional.
Entries
counseling or treatment
Provide the address of the health
Street address and city
State and Zip Code or Country
Allowed)
for that condition.
care professional.
(Multiple Entries
Provide the name, address, and
Name or same as above
Telephone Number or same as
Allowed)
telephone number of the
(Free Text)
above (Free Text)
agency/organization/facility
where counseling/treatment was
provided
Provide the address of the
Street address and city or same
State and Zip Code or Country
agency/organization/facility
as above
or same as above
where counseling/treatment was
provided
Do you have an additional instance where you ever received
YES (Yes adds another entry)
NO
I decline to
or are you currently receiving counseling or treatment for that
(Required
answer
DRAFT PRE-DECISIONAL DELIBERATIVE

condition? (You may choose not to answer this question.
However, such consultation or treatment will not disqualify
you and is considered to be a positive action.)
Have you ever chosen not to follow a prescribed course of
treatment for any of these conditions?

to
validate)
YES

Explanation (Free
Text)

(Required to
validate)

NO (Required to validate)

Section 22 – Police Record

Date (Estimated)

Provide a description of the
Description (Free Text)
specific nature of the offense.
Did this offense involve any of the following? (Check all that apply)
□ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally
recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom
you share a child in common?
□ Involve firearms or explosives?
□ Involve alcohol or drugs?
YES NO
Provide the location where the offense occurred.
Street address and city
State and Zip Code or Country
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police
YES NO
officer, sheriff, marshal or any other type of law enforcement official?
Arresting/citing/summoning agency
Branch
If Yes to Being
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Name (Free Text)
Arrested/Cited/
Provide the location of the law
Street address and city
State and Zip Code or Country
Summoned
enforcement agency.
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court
YES NO
in a criminal proceeding against you?
Branch - If No
You responded ‘No’ to “As a result of this offense were you charged, convicted, currently awaiting trial, and/or
to Charged or
ordered to appear in court in a criminal proceeding against you?”
Convicted
Provide Explanation
Explanation (Free Text)
Court information
Branch
Provide the name of the court.
Name of court (Free Text)
Provide the location of the court.
Street address and city
State and Zip Code or Country
If Yes to the
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as
Above
found guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded
Happening
guilty to a lesser offense, list separately both the original charge and the lesser offense.
Felony/Misdemeanor
Felony, Misdemeanor, Other
Charge
Charge (Free Text)
(Multiple
Outcome
Outcome (Free Text)
Date (Month/Year)
Entries
Were you sentenced as a result of this offense?
YES NO
Branch
Allowed)
Conviction detail
Provide a description of the sentence.
If Yes to
Charged or
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Branch
Convicted
Were you incarcerated as a result of that sentence for not less than 1 year?
YES NO
If Yes to
Being
If the conviction resulted in imprisonment, provide the dates
From Date (Estimated)
Sentenced
that you actually were incarcerated. (Not Applicable □ )
To Date (Estimated/Present)
If conviction resulted in probation or parole, provide the
From Date (Estimated)
dates of probation or parole. (Not Applicable □ )
To Date (Estimated/Present)
Trial detail
Branch
If No to
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal
YES NO
Being
charges for this offense?
Sentenced
Provide Explanation
Explanation (Free Text)
Do you have any other offenses where any of the following has happened to you?
YES
NO
• In the last seven (7) years have you been issued a summons, citation, or ticket to appear in
(Yes adds
(Required to
court in a criminal proceeding against you? (Do not include citations involving traffic
another entry)
validate)
infractions where the fine was less than $300 and did not include alcohol or drugs)
• In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or
any other type of law enforcement official?
• In the last seven (7) years have you been charged with, convicted of, or sentenced for 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 last 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?
Other than those offenses already listed, have you EVER had the following happen to you?
• 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,
DRAFT PRE-DECISIONAL DELIBERATIVE

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Provide the date of offense.

T

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.
Have any of the following happened? (If yes, you will be asked to provide details for each offense that pertains to the actions that are identified
below.)
• In the last 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 last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
• In the last seven (7) years have you been charged with, convicted of, or sentenced for 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 last 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?
YES NO

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 or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, 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?
YES NO

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T

Provide the date of the offense.
Date (Estimated)
Provide a description of the specific nature of the offense.
Description of nature of offense (Free Text)
Did this offense involve any of the following? (Check all that apply)
□ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally
recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom
you share a child in common?
□ Involve firearms or explosives?
□ Involve alcohol or drugs?
YES NO
Provide the name of the court.
Name of court (Free Text)
Provide the location of the court.
Street address and city
State and Zip Code or Country
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
Felony, Misdemeanor, Other
Charge
Charge (Free Text)
Outcome
Outcome (Free Text)
Date Month/Year
Date
Were you sentenced as a result of these charges?
YES NO
Branch
Conviction Detail
If Yes to the
Provide a description of the sentence.
Sentence description (Free Text)
Above
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Branch
Happening
Were you incarcerated as a result of that sentence for not less than 1 year?
YES NO
If Yes to Being
If the conviction resulted in imprisonment, provide the dates that you
From Date (Estimated)
Sentenced
(Multiple
actually were incarcerated. (Not Applicable □ )
To Date (Estimated/Present)
Entries
If the conviction resulted in probation or parole, provide the dates of
From Date (Estimated)
Allowed)
probation or parole. (Not Applicable □)
To Date (Estimated/Present)
Trial detail
Branch
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this
YES NO
If No to Being
offense?
Sentenced
Provide Explanation
Explanation (Free Text)
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
(Yes adds
(Required to
imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of that
another entry)
validate)
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 or
legally recognized civil union/domestic partner, former spouse or legally recognized civil
union/domestic partner, 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?
Is there currently a domestic violence protective order or restraining order issued against you?
YES NO
You responded ‘Yes’ to currently having a domestic violence protective order or restraining order issued against you.
Branch
If Yes to
Provide explanation:
Explanation (Free Text)
Domestic
Provide the date the order was issued.
Date (Estimated)
Violence
Provide the name of the court or agency that issued the order.
Name of court (Free Text)
(Multiple
Provide the location of the court or agency that issued the order.
Street address and city
State and Zip Code or Country
Entries
Do
you
have
another
domestic
violence
protective
order
or
YES
NO
Allowed)
restraining order currently issued against you to report?
(Yes adds another entry)
(Required to validate)

Section 23 – Illegal Use of Drugs and 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 in
accordance with Federal laws, even though permissible under state laws.
In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or controlled substance
YES NO
includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.
You answered ‘Yes’ to in the last seven (7) years having illegally used a drug or controlled substance.
Branch
Provide the type of drug or controlled substance.
Explanation if other (Free Text)
If Yes to
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Illegally Using □ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Drugs or
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Controlled
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Substances
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
DRAFT PRE-DECISIONAL DELIBERATIVE

Provide an estimate of the
Date (Estimated)
Provide an estimate of the month Date (Estimated)
month and year of first use.
and year of most recent use.
Provide nature of use, frequency, and number of times used.
Nature of use (Free Text)
Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while
YES NO
in a position directly and immediately affecting the public
Was your use while possessing a security clearance?
YES NO
Do you intend to use this drug or controlled substance in the future?
YES NO
Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Explanation
(Free Text)
Do you have an additional instance(s) of illegal use of a drug or controlled
YES
NO
substance to enter?
(Yes adds another entry)
(Required to validate)
In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production,
YES NO
transfer, shipping, receiving, handling or sale of any drug or controlled substance?
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.
Provide the type of drug or controlled substance.
If other explanation (Free Text)
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Branch
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
If Yes to
Provide an estimate of the month Date (Estimated)
Provide an estimate of the month and
Date (Estimated)
Illegal Drug
and year of first involvement.
year of most recent involvement.
Activity
Provide nature of and frequency of activity.
Nature of activity (Free Text)
Provide the reason(s) why you engaged in the activity.
Reason(s) (Free Text)
(Multiple
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official,
YES NO
Entries
or while in a position directly and immediately affecting the public safety?
Allowed)
Was your involvement while possessing a security clearance?
YES NO
Do you intend to engage in this activity in the future?
YES NO
You have indicated that you plan to engage in the illegal purchase, manufacture,
Explanation (Free Text)
Branch
If Yes to
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale
Future Activity of a drug or controlled substance in the future. Provide explanation.
Do you have an additional instance(s) of having been involved in the illegal purchase,
YES
NO
manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale (Yes adds
(Required to
of a drug or controlled substance to enter?
another entry)
validate)
Have you EVER illegally used or otherwise been illegally involved with a drug or controlled substance while possessing a security
YES NO
clearance other than previously listed?
You responded ‘Yes’ to having EVER illegally used or otherwise been involved with a drug or controlled substance while
Branch
If Yes to Use
possessing a security clearance, other than previously listed.
While
Provide a description of your involvement.
Description (Free Text)
Possessing a
Provide the dates of involvement/use.
From Date (Estimated)
To Date (Estimated/Present)
Clearance
Provide an estimate of the number of times you used and/or were involved
Estimate (Free Text)
(Multiple
with this drug or controlled substance while possessing a security clearance.
Entries
Do you have an additional instance(s) of the illegal use or involvement with a
YES
NO
Allowed)
drug or controlled substance while possessing a security clearance to enter?
(Yes adds another entry) (Required to validate)
Have you EVER illegally used or otherwise been involved with a drug or controlled substance while employed as a law
YES NO
enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety
other than previously listed?
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
Branch
the public safety other than previously listed.
If Yes to Use
Provide a description of the drugs or controlled substances used and your involvement.
Description (Free Text)
While in Law
Enforcement
Provide the dates of involvement/use.
From Date (Estimated)
To Date (Estimated/Present)
Provide an estimate the number of times you used and/or were involved this drug or
Estimate (Free Text)
(Multiple
controlled substance while employed in this capacity.
Entries
Do you have an additional instance(s) of illegal use or involvement with a drug or controlled
YES
NO
Allowed)
substance while employed as a law enforcement officer, prosecutor, or courtroom official; or
(Yes adds
(Required to
while in a position directly and immediately affecting the public safety to enter?
another entry)
validate)
In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the
YES NO
drugs were prescribed for you or someone else?
You responded ‘Yes’ to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless of
Branch
whether the drugs were prescribed for you or someone else.
If Yes to
Provide the name of the prescription drug that you misused.
Drug names (Free Text)
Misuse of
Provide the dates of involvement in the above.
From Date (Estimated)
To Date (Estimated/Present)
Prescription
Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Reasons (Free Text)
Drugs
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official,
YES NO
or while in a position directly and immediately affecting the public safety?
(Multiple
Was your involvement while possessing a security clearance?
YES NO
Entries
Do you have an additional instance(s) of intentionally engaging in the misuse
YES
NO
Allowed)
of prescription drugs in the last seven (7) years to enter?
(Yes adds another entry) (Required to validate)
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or
YES NO
controlled substances?
You responded ‘Yes’ to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal
Branch
use of drugs or controlled substances
If Yes to
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
Being Ordered controlled substances? (Check all that apply)
Treatment for
□ An employer, military commander, or employee assistance program
□ A medical professional
DRAFT PRE-DECISIONAL DELIBERATIVE

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(Multiple
Entries
Allowed)

□ 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
Explanation (Free Text)
Did you take action to receive counseling or treatment?
YES NO
(Multiple
Branch If No
You have indicated that you did not receive treatment. Provide explanation.
Explanation (Free Text)
Entries
to Action Taken
Allowed)
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
Branch
□ Inhalants (Such as toluene, amyl nitrate, etc.)
If Yes to Action □ Other (Provide explanation):
Taken
Explanation (Free Text)
Provide the name of the treatment
Name (Free Text)
provider. (Last name, First name)
Provide the address for this treatment provider. Street address and city
State and Zip Code or Country
Provide a telephone number for the treatment provider.
Number/Extension Time Day
Night Both _Check box if
International
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
Did you successfully complete the treatment?
YES NO
Branch If No
You have indicated that you did not successfully
Explanation (Free Text)
to Successful
complete the treatment. Provide explanation.
Treatment
Do you have another instance of having been ordered, advised, or asked to
YES
NO
seek drug or controlled substance counseling or treatment to enter?
(Yes adds another entry) (Required to validate)
Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance?
YES NO
Voluntary treatment detail
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Branch
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Ketamine (Such as special K, jet, etc.)
If Yes to
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Voluntarily
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Seeking
Provide the name of the treatment provider. (Last name, First name)
Name (Free Text)
Treatment for
Provide the address for this treatment provider.
Street address and city
State and Zip Code or Country
the Misuse of
Provide a telephone number for the treatment provider.
Number/Extension Time Day
Drugs
Night Both _Check box if
International
(Multiple
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
Entries
Did
you
successfully
complete
the
treatment?
YES NO
Allowed)
Branch If No to
You have indicated that you did not you successfully complete the
Explanation (Free Text)
Successful Treatment treatment. Provide explanation.
Do you have another instance of EVER voluntarily seeking counseling
YES
NO
or treatment as a result of your use of a drug or controlled substance?
(Yes adds another entry)
(Required to validate)

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the Misuse of
Drugs

Section 24 – Use of Alcohol

D

In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your professional or personal
YES NO
relationships, your finances, or resulted in intervention by law enforcement/public safety personnel?
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.
Branch
Provide the month/year when this negative impact occurred.
Date (Estimated)
If negative
Provide an explanation of the circumstances and the negative impact.
Provide circumstances (Free Text)
impact
Provide negative impact (Free Text)
(Multiple
Provide dates of involvement or use.
From Date (Estimated)
To Date (Estimated/Present)
Entries
Has the use of alcohol had other negative impacts on your work performance, your
YES
NO
Allowed)
professional or personal relationships, your finances, or resulted in intervention by law
(Yes adds
(Required to
enforcement/public safety personnel?
another entry)
validate)
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol?
YES NO
You responded ‘Yes” to having been ordered, advised or asked to seek counseling or treatment as a result of your use of alcohol.
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check
Branch
all that apply)
□ An employer, military commander, or employee assistance program
□ A medical professional
If Yes to
□ A mental health professional
□ A court official / judge
Ordered to
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above. □ Other (Provide Explanation)
Seek
Other explanation (Free Text) Did you take action to seek counseling or treatment?
YES NO
Counseling
Branch If No
You responded ‘No’ to having taken action to seek counseling or treatment.
Explanation (Free Text)
Action Taken
Explain the reasons for not taking action to seek counseling or treatment.
(Multiple
You responded ‘Yes’ to having taken action to seek counseling or treatment.
Entries
Provide the dates of counseling or
From Date (Estimated)
To Date (Estimated/Present)
Allowed)
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treatment.
Provide the name of the individual counselor or treatment provider.
Counselor name (Free Text)

DRAFT PRE-DECISIONAL DELIBERATIVE

If Yes to
Taking Action

Provide the full address of the counseling/treatment provider.

Provide telephone number.

Number/Ext
ension Time
Day Night Both
_Check box if
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Street address and city
State and Zip Code or Country
Did you successfully complete the treatment program?
YES NO
Branch If No to
You responded “No” to having successfully completed
Explanation (Free Text)
Successful Completion
the treatment program. Provide explanation
Do you have additional instances of having been ordered, advised or asked
YES
NO
to seek counseling or treatment as a result of your use of alcohol to enter?
(Yes adds another entry) (Required to validate)
Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
YES NO
You responded ‘Yes’ to voluntarily seeking counseling or treatment.
Provide the dates of counseling or treatment.
From Date (Estimated)
To Date (Estimated/Present)
Provide the name of the individual counselor or treatment provider.
Counselor name (Free Text)
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Provide the full address of the counseling/treatment provider.
Street address and city
State and Zip Code or Country
If Yes to
Provide telephone number.
Number/Ext
Did you successfully complete the treatment program?
YES NO
to Seeking
ension Time Day
Counseling
Night Both
_Check box if
(Multiple
International
Entries
You answered ‘No’ to having successfully completed the treatment
Explanation (Free Text)
Branch
Allowed)
If Unsuccessful
program. Provide explanation:
Do you have additional instances where you have voluntarily sought
YES
NO
counseling or treatment as a result of your use of alcohol to enter?
(Yes adds another entry)
(Required to validate)
Have you EVER received counseling or treatment as a result of your use of alcohol in addition to what you have already listed on
YES NO
this form?
You responded ‘Yes’ to having EVER received counseling or treatment as a result of your use of alcohol.
Provide the name of individual counselor or treatment provider.
Counselor name (Free Text)
Branch
Provide the full address of counseling/treatment
Street address and city
County
State and Zip Code or Country
provider.
If Yes to
Provide the name of agency/organization where counseling/treatment was provided.
Agency name (Free Text)
to Receiving
Provide the address of agency/organization where counseling/treatment was provided: □ Same as above
Counseling
Street address and city
State and Zip Code or Country
Provide the date counseling or
Date (Estimated)
Provide the date counseling
Date (Estimated/Present)
(Multiple
treatment
began.
or
treatment
ended
Entries
Did you successfully complete your counseling or treatment?
Explanation for Yes or No (Free Text)
YES NO
Allowed)
Did you receive alcohol-related counseling or treatment another
YES (Yes adds another entry)
NO (Required to validate)
time?

Section 25 – Investigations and Clearance Record

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Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance
YES NO
eligibility/access?
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.
Provide the investigating
□ U.S. Department of Defense
□ U.S. Department of State
agency:
□ U.S. Office of Personnel Management
□ Federal Bureau of Investigation
□ U.S. Department of Treasury (Provide name of bureau)
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□ U.S. Department of Homeland Security
Explanation or name of
If Yes to Having
□ Foreign government, (Provide name of government) □ I don’t know
government (Free Text)
Ever Been
□ Other (Provide explanation)
Investigated
Date the investigation was completed.
□ I don’t know
Date (Estimated)
Provide the name of agency that issued the clearance eligibility/access if different from the
Name (Free Text)
(Multiple Entries
investigating agency.
Allowed)
Provide the date clearance eligibility/access was granted. □ I don’t know
Date (Estimated)
Provide the level of clearance
□ None
□ Confidential
□ Secret
□ Top Secret
eligibility/access granted.
□ Sensitive Compartmented Information (SCI) □ Q
□L
□ I don’t know
□ Issued by foreign country
□ Other (Provide explanation)
Explanation (Free Text)
Do you have another investigation to enter?
YES (Yes adds another entry)
NO (Required to validate)
Have you EVER had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An administrative
YES NO
downgrade or administrative termination of a security clearance is not a revocation.)
You responded ‘Yes’ to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.
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Provide the date security clearance eligibility/access authorization was denied, suspended or revoked.
Date (Estimated)
If Yes to Denied
Provide the name of the agency that took the action.
Name (Free Text)
Provide an explanation of the circumstances of the denial, suspension or revocation action.
Explanation (Free Text)
(Multiple Entries
Do you have another denied, revoked or suspended security
YES
NO
Allowed)
clearance eligibility/access authorization to enter?
(Yes adds another entry) (Required to validate)
Have you EVER been debarred from government employment?
YES
NO
You responded ‘Yes’ to having EVER been debarred from government employment.
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Provide the name of the government agency taking debarment action.
Agency name
If Yes to
Debarment
Provide the date the debarment occurred.
Date (Estimated)
(Multiple Entries
Provide an explanation of the circumstances of the debarment.
Circumstances (Free text)
Allowed)
Do you have another Government debarment to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 26 – Financial Record
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
You responded ‘Yes’ to having filed a petition under any chapter of the bankruptcy code.
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DRAFT PRE-DECISIONAL DELIBERATIVE

YES

NO

Select the applicable bankruptcy petition type:
□ Chapter 7 □ Chapter 11 □ Chapter 12 □ Chapter 13
Provide the bankruptcy court docket/account number.
Account Number (Free Text)
Provide the date bankruptcy was filed.
Date (Estimated)
Provide date of bankruptcy discharge. □ Not Applicable
Date (Estimated)
(Multiple
Provide the total amount (in U.S. dollars) involved in the bankruptcy. □ Estimated
Amount (Free Text)
Entries
Provide the name debt is recorded under.
Last
First
Middle
Suffix
Allowed)
Provide the name of the court involved.
Court Name (Free Text)
Provide the address of the court involved.
Street address and City
State and Zip Code or Country
Provide the name of the trustee for this bankruptcy.
Name (Free Text)
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Provide the address of the trustee for this bankruptcy.
If Chapter 13
Street address and City
State and Zip Code or Country
Were you discharged of all debts claimed in the bankruptcy? Provide Explanation
Explanation (Free Text)
YES
NO
In the last seven (7) years, have you filed any additional petitions under any
YES
NO
chapter of the bankruptcy code?
(Yes adds another entry) (Required to validate)
Have you EVER experienced financial problems due to gambling?
YES
NO
You responded ‘Yes’ to having EVER experienced financial problems due to gambling.
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If Yes to
Provide the date range of your financial problems due to gambling.
From Date (Estimated)
To Date (Estimated/Present)
Financial
Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.
Amount
(Free Text)
Problems Due
Provide a description of your financial problems due to gambling.
Description (Free Text)
to Gambling
If you have taken any action(s) to rectify your financial problems due to gambling, provide a
Description (Free Text)
(Multiple
description of your actions. If you have not taken any action(s) provide explanation.
Entries
Have you EVER experienced additional financial problems
YES (Yes adds another entry)
NO (Required to validate)
Allowed)
due to gambling?
In the last seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?
YES
NO
You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Did you fail to file, pay as required, or both? □ File □ Pay □ Both
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Provide the year you failed to file or pay your Federal, state or other taxes. (Estimated)
Provide the reason(s) for your failure to file or pay required taxes.
Reasons (Free Text)
If Yes to
Provide the Federal, state or other agency to which you failed to file or pay taxes.
Agency (Free Text)
Failing to
Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.).
Tax Type (Free Text)
File/Pay Taxes
Provide the amount (in U.S. dollars) of the taxes. □ Estimated
Amount (Free Text)
Provide date satisfied. □ Not applicable
Date (Estimated)
(Multiple
Provide
a
description
of
any
action(s)
you
have
taken
to
satisfy
this
debt
(such
as
withholdings,
Description (Free Text)
Entries
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Allowed)
Are there any other instances in the last seven (7) years where you failed to
YES
NO
file or pay Federal, state or other taxes when required by law or ordinance?
(Yes adds another entry) (Required to validate)
In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement for a travel or
YES
NO
credit card provided by your employer?
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.
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Provide the name of the agency or company.
Agency (Free Text)
Provide the address of the agency or company.
Street address and City
State and Zip Code or Country
If Yes to
Provide the date of your counseling, warning, or disciplinary action.
Month/Year
Est.
Violation of
Credit/Travel
Provide the reason(s) for the counseling, warning or disciplinary action.
Reasons (Free Text)
Card Terms
Provide the amount (in U.S. dollars) of violation. □ Estimated
Amount (Free Text)
Provide a description of any action(s) you have taken to rectify this situation. If you have not
Description (Free Text)
(Multiple
taken any action(s) provide explanation.
Entries
Are there any other instances in the last seven (7) years where you have been counseled,
YES
NO
Allowed)
warned, or disciplined for violating the terms of agreement for a travel or credit card provided
(Yes adds
(Required to
by your employer?
another entry)
validate)
Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve your financial
YES
NO
difficulties?
You responded ‘Yes’ to currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to
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resolve your financial difficulties.
Provide explanation (Free Text)
Provide the name of the credit counseling organization or resource.
Name (Free Text)
If Yes to
Number / Ext
Seeking Credit Provide the phone number of the credit counseling organization.
Counseling
Provide the location of the credit counseling organization.
City
State
As a result of this counseling provide a description of any action(s) you have taken to
Description (Free Text)
(Multiple
resolve your financial difficulties. If you have not taken any action(s) provide explanation.
Entries
Are you currently utilizing, or seeking assistance from any other credit counseling service
YES (Yes adds
NO (Required
Allowed)
or other similar resource to resolve your financial difficulties?
another entry)
to validate)
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).
• In the last seven (7) years, you have been delinquent on alimony or child support payments.
• In the last 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 last 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).
YES NO
You answered ‘Yes’ to having experienced one or more of the previously stated financial issues.
Provide the name of agency/organization/individual to which debt is/was owed.
Name (Free Text)

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If Yes to
Having Filed
Bankruptcy

DRAFT PRE-DECISIONAL DELIBERATIVE

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Did/does this financial issue include any of the following: (Check all that apply)
□ In the last seven (7) years , you have been delinquent on alimony or child support payments.
□ In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole
Branch
debtor, as well as those for which you were a cosigner or guarantor).
□ In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial
If Yes to
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
Having
□ You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as
Financial
those for which you are a cosigner or guarantor).
Issues
Involving
YES NO
Enforcement
Provide the associated loan / account number(s) involved.
Loan / account number (Free Text)
Identify/describe the type of property involved (if any).
Property type (Free Text)
(Multiple
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated
Amount (Free Text)
Entries
Provide the reason(s) for the financial issue.
Reasons (Free Text)
Allowed)
Provide the current status of the financial issue.
Status (Free Text)
Provide the date the financial issue began.
Date (Estimated)
Provide date the financial issue was resolved. □ Not resolved
Date (Estimated)
Provide the name of the court involved.
Court name (Free Text)
Provide the address of the court involved.
Street address and City
State and Zip Code or Country
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
frequency and amount of payments, etc.). If you have not taken any provide explanation.
Other than previously listed, are there any other instances of the following occurrences?
• In the last seven (7) years, you have been delinquent on alimony or child support payments.
• In the last 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 last 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).
YES (Yes adds another entry)
NO (Required to validate)
Other than previously listed, have any of the following happened?
• In the last 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 last 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 last 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 last 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 last seven (7) years, you were evicted for non-payment?
• In the last seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason?
• In the last 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).
YES NO
You answered ‘Yes’ to having experienced one or more of the previously stated financial issues.
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following: (Check all that apply)
□ In the last 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 last 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 last 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 last seven (7) years you had an account or credit card suspended, charged off, or cancelled for failing to pay as agreed.
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(Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
□ In the last seven (7) years you were evicted for non-payment.
If Yes to
□ In the last seven (7) years you had wages, benefits, or assets garnished or attached for any reason.
Having
□ In the last seven (7) years you were over 120 days delinquent on any debt not previously entered. (Include financial obligations
Financial
for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
Issues
□ You are currently over 120 days delinquent on any debt. (Include financial obligations for which you are the sole debtor, as well
Involving
as those for which you are a cosigner or guarantor).
Routine
YES NO
Accounts
Provide the associated loan / account number(s) involved.
Loan / account number (Free Text)
Identify/describe the type of property involved (if any).
Property type (Free Text)
(Multiple
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated
Amount (Free Text)
Entries
Provide
the
reason(s)
for
the
financial
issue.
Reasons (Free Text)
Allowed)
Provide the current status of the financial issue.
Status (Free Text)
Provide date the financial issue was resolved. □ Not resolved
Date (Estimated)
Provide the date the financial issue began.
Date (Estimated)
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.

DRAFT PRE-DECISIONAL DELIBERATIVE

Other than previously listed, are there any other instances of the following occurrences?
□ Yes □ No
• In the last 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 last 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 last 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 last 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 last seven (7) years, you have been evicted for non-payment.
• In the last seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason.
• In the last 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).
YES (Yes adds another entry)
NO (Required to validate)

Section 27 – Use of Information Technology Systems

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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.
In the last seven (7) years have you illegally or without proper authorization accessed or attempted to access any information
YES NO
technology system?
You responded ‘Yes’ to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter
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into any information technology system.
If Yes to
Provide the date of the incident.
Date (Estimated)
Unauthorized
Provide a description of the nature of the incident or offense.
Description of incident (Free Text)
Access
Provide the location where the incident took place.
Street address and City
State and Zip Code or Country
(Multiple
Provide a description of the action (administrative, criminal or other) taken as a result of
Description (Free Text)
Entries
this incident.
Allowed)
Are there any other incidents to report?
YES (Yes adds another entry)
NO (Required to validate)
In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or denied others access to
YES NO
information residing on an information technology system or attempted any of the above?
You responded ‘Yes’ to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or
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denied others access to information residing on an information technology system or attempted any of the above.
If Yes to
Provide the date of the incident.
Date (Estimated)
Manipulating
Provide a description of the nature of the incident or offense.
Description of incident (Free Text)
Access
(Multiple
Provide the location where the incident took place.
Street address and City
State and Zip Code or Country
Entries
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Description (Free Text)
Allowed)
Are there any other incidents to report?
YES (Yes adds another entry)
NO (Required to validate)
In the last seven (7) years have you introduced, removed, or used hardware, software, or media in connection with any information
YES NO
technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted
any of the above?
You responded ‘Yes’ to having in the last seven (7) years introduced, removed, or used hardware, software, or media in
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connection with any information technology system without authorization, when specifically prohibited by rules, procedures,
If Yes to
guidelines, or regulations or attempted any of the above.
Unlawful Use
Provide the date of the incident.
Date (Estimated)
Provide a description of the nature of the incident or offense.
Description (Free Text)
(Multiple
Provide the location where the incident took place.
Street address and City
State and Zip Code or Country
Entries
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Description (Free Text)
Allowed)
Are there any other incidents to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 28 – Involvement in Non-Criminal Court Actions

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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
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
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ten (10) years.
If Yes to
Provide the date of the civil action
Date (Estimated)
Provide the court name
Court name (Free Text)
Having Non
Provide the address of the court.
Street address and City
State and Zip Code or Country
Criminal
Provide details of the nature of the action.
Details (Free Text)
Court Actions
Provide a description of the results of the action.
Results (Free Text)
(Multiple
Provide the name(s) of the principal parties involved in the court action.
Names (Free Text)
Entries
Are there any other civil court actions in the last ten (10) years to report?
YES
NO
Allowed)
(Yes adds another entry) (Required to validate)

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.
Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the
YES NO
organization’s dedication to that end, or with the specific intent to further such activities?
You responded ‘Yes’ to being or EVER having been a member of an organization dedicated to terrorism, either with an
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awareness of the organization’s dedication to that end, or with the specific intent to further such activities.
If Yes to Being a
Provide the full name of the organization.
Organization name (Free Text)
Member of a
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
DRAFT PRE-DECISIONAL DELIBERATIVE

Provide the dates of your involvement with the organization.
From Date (Estimated)
To Date (Estimated/Present)
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
(Multiple Entries
Provide a description of the nature of and reasons for your involvement with the organization.
Involvement (Free Text)
Allowed)
Do you have any other instances of being a member of an organization dedicated to
YES
NO
terrorism, either with an awareness of the organization’s dedication to that end, or with the
(Yes adds
(Required to
specific intent to further such activities to report?
another entry)
validate)
Have you EVER knowingly engaged in any acts of terrorism?
YES NO
Branch If Yes
You responded ‘Yes’ to EVER having knowingly engaged in any acts of terrorism.
Engaging in
Describe the nature and reasons for the activity.
Nature and reasons (Free Text)
Terrorism
Provide the dates for any such activities.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of knowingly engaging in acts of
YES
NO
Allowed)
terrorism to report?
(Yes adds another entry)
(Required to validate)
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?
YES
NO
You responded ‘Yes’ to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government
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by force.
If Yes to
Provide the reason(s) for advocating acts of terrorism.
Reasons (Free Text)
Advocating
Provide the dates of advocating acts of terrorism.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of advocating acts of terrorism or activities
YES (Yes adds
NO (Required to
Allowed)
designed to overthrow the U.S. Government by force to report?
another entry)
validate)
Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States
YES NO
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?
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
Branch
that end or with the specific intent to further such activities.
Provide the full name of the organization.
Organization name (Free Text)
If Yes to being
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Member of
Provide the dates of your involvement with the organization.
From Date (Estimated)
To Date (Estimated/Present)
Organization
Using Violence
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
to Overthrow the
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
U.S. Govt.
Provide a description of the nature of and reasons for your involvement with the organization.
Description (Free Text)
Do you have any other instances of being a member of an organization dedicated to the use
YES
NO
(Multiple Entries
of violence or force to overthrow the United States Government, which engaged in
(Yes adds
(Required to
Allowed)
activities to that end with an awareness of the organization’s dedication to that end or with
another entry)
validate)
the specific intent to further such activities to report?
Have you EVER been a member of an organization that advocates or practices commission of acts of force or violence to
YES NO
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?
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.
Provide the full name of the organization.
Organization Name (Free Text)
Branch
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
If Yes to Being a
Provide the dates of your involvement with the organization.
From Date (Estimated)
To Date (Estimated/Present)
Member of
Organization
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Using Violence
Provide all contributions (in U.S. dollars) made to the organization, if any.
Contributions (Free Text)
□ No contributions made
(Multiple Entries
Provide a description of the nature of and reasons for your involvement with the organization.
Involvement (Free Text)
Allowed)
Do you have any other instances of being a member of an organization that advocates or
YES
NO
practices commission of acts of force or violence to discourage others from exercising
(Yes adds
(Required to
their rights under the U.S. Constitution or any state of the United States with the specific another entry)
validate)
intent to further such action to report?
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?
YES
NO
Branch If Yes to You responded ‘Yes’ to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Describe the nature and reasons for the activity.
Reasons (Free Text)
Activities to
Overthrow
Provide the dates of such activities.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of having knowingly engaged in activities YES
NO
Allowed)
designed to overthrow the U.S. Government by force to report?
(Yes adds another entry) (Required to validate)
Have you EVER associated with anyone involved in activities to further terrorism?
YES
NO
Terrorism Association Detail
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If Yes to Having
Provide Explanation.
Explanation (Free Text)
Terrorism
Association

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Terrorist
Organization

Additional Comments

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 further affirm that, to the best of my knowledge, I have not included any classified information herein. 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, falsifying, or including classified
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.
DRAFT PRE-DECISIONAL DELIBERATIVE

Date (mm/dd/yyyy)

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Signature (Sign in ink)

DRAFT PRE-DECISIONAL DELIBERATIVE

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.

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I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation, reinvestigation or ongoing evaluation (i.e. continuous evaluation) of my
eligibility for access to classified information or, when applicable, eligibility to hold a national security sensitive
position 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 current
and historic, academic, residential, achievement, performance, attendance, disciplinary, employment, criminal,
financial, and credit information, and publicly available social media information. I authorize the Federal agency
conducting my investigation, reinvestigation, or ongoing evaluation (i.e. continuous evaluation) of eligibility to
disclose the record of investigation or ongoing evaluation to the requesting agency for the purpose of making a
determination of suitability or initial or continued eligibility for a national security position or eligibility for access
to classified information.

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I Understand that, for these purposes, publicly available social media information includes any electronic social
media information that has been published or broadcast for public consumption, is available on request to the public,
is accessible on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully
accessible to the public. I further understand that this authorization does not require me to provide passwords; log
into a private account; or take any action that would disclose non-publicly available social media information.
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.

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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 Homeland Security, the Office of the Director of
National Intelligence, 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.

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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
occupy a national security sensitive position or require eligibility for access to classified information.

Signature (Sign in ink)

Full name (Type or print legibly)
DRAFT PRE-DECISIONAL DELIBERATIVE

Date signed (mm/dd/yyyy)

Other names used
City (Country)

State

Social Security Number

ZIP Code

Telephone number

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Current street address Apt. #

Date of birth

DRAFT PRE-DECISIONAL DELIBERATIVE

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 Section 21 of the Standard Form 86 (SF-86), carefully read this authorization to release
information about you, then sign and date it in ink.

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This is an authorization for the investigator to ask your health practitioner(s) the questions below concerning your
mental health consultations. The U.S. government recognizes the critical importance of mental health and
advocates proactive management of mental health conditions to support the wellness and recovery of Federal
employees and others. The government recognizes that mental health counseling and treatment may provide
important support for those who have experienced traumatic events, as well as for those with other mental health
conditions. While most individuals with mental health conditions do not present security risks, there may be times
when such a condition can affect a person’s eligibility for a security clearance. Seeking or receiving mental health
care for personal wellness and recovery may contribute favorably to decisions about your eligibility. Your
signature will allow the practitioner(s) to answer only those questions identified below.

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Authorization
I am seeking assignment to or retention in a national security sensitive position. As part of the investigative
process, I hereby authorize the investigator, special agent, or duly accredited representative of the authorized
Federal agency conducting my background investigation, reinvestigation, or ongoing evaluation (i.e. continuous
evaluation) of eligibility for access to classified information or eligibility to hold a national security sensitive
position to request, and my health practitioner(s) to provide, the information requested below, 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
my health care provider/entity. Revocation of this authorization is not effective until received by my health care
provider/entity. 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.

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I understand the information disclosed pursuant to this authorization for use by the Federal Government only
for purposes provided in the Standard Form 86 will no longer be covered by the HIPAA Privacy Rule, and
that the Federal Government may redisclose the information as authorized by law, subject to Privacy Act
safeguards.
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.

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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

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
trustworthiness?
__YES __NO
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
DRAFT PRE-DECISIONAL DELIBERATIVE

Dates of treatment?

Practitioner name

Date signed (mm/dd/yyyy)

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Signature (Sign in ink)

DRAFT PRE-DECISIONAL DELIBERATIVE

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

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The Federal government requires information from one or more consumer reporting agencies in order to obtain
information in connection with a background investigation, reinvestigation, or ongoing evaluation (i.e. continuous
evaluation) of eligibility for access to classified information, or when applicable, eligibility to hold a national
security sensitive position. 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

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I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized Federal
agency conducting my initial background investigation, reinvestigation, or ongoing evaluation (i.e. continuous
evaluation) of my eligibility for access to classified information, or when applicable, eligibility to hold a national
security sensitive position to request, and any consumer reporting agency to provide, such reports for purposes
described above.

Note: If you have a security freeze on your consumer or credit report file, we will not be able to access the
information necessary to complete your investigation, which can adversely affect your eligibility for a national
security position. To avoid such delays, you should expeditiously respond to any requests made to release the credit
freeze for the purposes as described above.
Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I
occupy a national security sensitive position or require eligibility for access to classified information.

Social Security Number

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Print name

D

Signature (Sign in ink)

DRAFT PRE-DECISIONAL DELIBERATIVE

Date (mm/dd/yyyy)