83C Table of Changes

TABLE OF CHANGES - FORM

Form No. 70-009

Title: 287g Questionnaire

Reason for Revision: To correct typeset, branding a re-word several questions.

Current Section and Page Number	Current Text	Proposed Text
Page 1, “To” field near header	To:_______________________________ (Local law enforcement agency leader requesting 287(g) Partnership)	TO: Agency: Address: Attn:
Page 1, “From”	From:ICE OSLC Group LEO Candidate’s Name ____________________	Candidate’s Name_______ Date_______________
Instructions	As part of your request to enter into a 287(g) partnership with ICE pursuant to a written agreement in the form of a Memorandum of Agreement (MOA), please provide, to the best of your knowledge, full and complete responses to the following questions for each proposed law enforcement officer (LEO) candidate that is employed by your agency. This is a preliminary questionnaire and does not constitute the full scope of ICE inquiry into the background of any particular 287(g) candidate.	As part of your request to enter into a 287(g) partnership with ICE via the Memorandum of Agreement (MOA), please provide, to the best of your knowledge, full and complete responses to the following questions concerning the law enforcement officer (LEO) candidate. This preliminary partnership questionnaire does not constitute the full scope of ICE inquiry into any particular 287(g) candidate’s background. The LEO’s supervisor must complete this questionnaire.
Questionnaire portion, page 1	Is the candidate a sworn/certified, full-time law enforcement officer employed by your agency? (TF only) yes no	Is the LEO candidate a sworn or certified law enforcement officer employed by your agency? Yes No
	Is the candidate a United States citizen? Yes No	Is the LEO candidate a United States citizen Yes No, A#________________
Questionnaire portion, page 2	Has the candidate, at any time, been suspected, accused, or proven to have engaged in any of the following types of conduct or misconduct (provide details for affirmative answers): Employee misconduct in any context yes no; Criminal or dishonest conduct to include, but not be limited to, false statements, testimony, or reports related to any matter within the scope of the employee’s law enforcement duties yes no; Any conduct related to spousal/partner/domestic/family abuse or battering yes no; Any conduct resulting in any internal agency investigation, whether formal or informal, regardless of whether any type of disciplinary action was taken against the LEO yes no; Refusal to cooperate with any inquiry, official or unofficial, or investigation or to furnish any type of requested testimony yes no; Abuse of alcohol or any drug to the degree that is has affected, or could affect the candidate’s performance of law enforcement duties; yes no ; and, Knowing and willful engagement in acts or activities designed to overthrow the United States government by force yes no	Has the LEO candidate ever been suspected, accused, or proven to have engaged in any of the following types of conduct or misconduct (provide details and additional documentation for affirmative answers): Employee misconduct which would prohibit him or her from performing immigration officer functions? Yes No If “yes”, explain: _____________________________________________________________ Criminal or dishonest conduct to include, but not be limited to, false statements, testimony, or reports related to any matter within the scope of his or her law enforcement duties? Yes No If “yes”, explain: _____________________________________________________________ Any conduct related to spousal, partner, domestic, family abuse or battery? Yes No (A “no” answer affirms that the candidate is not prohibited from carrying a firearm pursuant to any State or Federal law, including, but not limited to, the Lautenberg Amendment (18 U.S.C.§ 922(g)(8) or (9)). If “yes”, explain: _____________________________________________________________ Any action resulting in any internal agency investigation, formal or informal, regardless of whether any type of disciplinary action was taken against the LEO? Yes No If “yes”, explain: _____________________________________________________________ Refusal to cooperate with any inquiry, official or unofficial, or investigation or to furnish any type of requested testimony? Yes No If “yes”, explain: _____________________________________________________________ Abuse of alcohol or any drug to the degree that it has affected, or could affect the LEO candidate’s performance of law enforcement duties? Yes No If “yes”, explain: _____________________________________________________________ Use of illegal narcotics? Yes No If “yes”, explain: _____________________________________________________________ Knowing and willful engagement in acts or activities designed to overthrow the United States government? Yes No If “yes”, explain: _____________________________________________________________
Affirmation portion, page 3	_____________________________________ Printed Name and Signature (sign in ink) _____________________________________ Title __________________ Date	____________________________________ Signature ____________________________________ Printed Name _____________________________________ Title _______________ Date
	The form should be mailed to: U.S. Immigration and Customs Enforcement Office of State and Local Coordination Potomac Center North 500 12th St, SW, 5th Floor Washington, DC 20536 to the attention of your designated OSLC Point of Contact.	Mail this form to: U.S. Immigration and Customs Enforcement ATTN: Designated 287(g) Program Point of Contact Potomac Center North 500 12th St, SW, 5th Floor Washington, DC 20536
Page 3	NONE	PRIVACY ACT STATEMENT AUTHORITY: Information about the law enforcement officer (LEO) candidate is collected and maintained pursuant to the authority of section 287(g) of the Immigration and Nationality Act (INA), which authorizes ICE to delegate Federal immigration enforcement authorities to state and local law enforcement agencies. Under the 287g Program, ICE enters into agreements with state and local law enforcement agencies to delegate to the agencies’ LEOs the authority to enforce certain federal immigration laws. PRINCIPAL PURPOSE(S): LEO candidate information is being collected on this form to make a preliminary determination about the suitability, authority and eligibility of the candidate to participate in the 287g program. Further background inquiries may occur as part of the eligibility process. If determined to be eligible, the LEO candidate will be certified to enforce certain federal immigration laws, and will have the authority to question and detain individuals for potential removal from the United States based upon their immigration status. ROUTINE USE(S): The information you provide may be shared internally within the U.S. Department of Homeland Security (DHS) for appropriate action. Pursuant to the routine uses published in DHS/ALL-023 Department of Homeland Security Personnel Security Management System of Records (February 23, 2010 75 F.R. 8088), ICE may share this information with federal, state, local, tribal, foreign, or international agencies if the information is relevant and necessary to ICE’s decision to delegate authority or issue a security clearance to the LEO candidate; or as otherwise authorized under the Privacy Act of 1974, 5 U.S.C. § 552a(b), and pursuant to the routine uses published in the cited DHS system of records notice. DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested will disqualify the LEO candidate from further participation in the 287g Program.