Form 1600-07 Background Investigation Questionnaire for Contractors

OMB NUMBER: 3064-0072 EXPIRATION DATE: 12/31/2015
Federal Deposit Insurance Corporation BACKGROUND INVESTIGATION QUESTIONNAIRE FOR CONTRACTORS
INSTRUCTIONS: Complete each item as it applies to your firm. (Please type or print.) An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
SECTION I - CONTRACTOR INFORMATION
1. NAME OF CONTRACTOR (Do not use acronyms unless applicable.)			2. FEDERAL TAX ID NUMBER
     			     
3. TRADE NAME (If different from contractor name)
     
4. TYPE OF BUSINESS
     
5. STREET ADDRESS (Include City, State, and ZIP Code)		6. E-MAIL ADDRESS
     		     
7. SOLICITATION/CONTRACT NO. (If applicable)	8. CONTACT NAME		9. TELEPHONE NUMBER
     	     		     
SECTION II - JOINT VENTURE ENTITIES
10. NAME OF JOINT VENTURE (1)			11. FEDERAL TAX ID NUMBER
     			     
12. STREET ADDRESS (Include City, State, and ZIP Code)
     
13. CONTACT NAME			14. TELEPHONE NUMBER
     			     
15. NAME OF JOINT VENTURE (2)			16. FEDERAL TAX NUMBER
     			     
17. STREET ADDRESS (Include, City, State, and ZIP Code)
     
18. CONTACT NAME			19. TELEPHONE NUMBER
     			     
Check this box if information on additional entities has been attached to this form.
SECTION III - CERTIFICATION AND AUTHORIZATION
I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information and the information provided to the FDIC regarding contracting with the FDIC in order to verify the contractor's fitness and integrity to provide services to or on behalf of the Federal Deposit Insurance Corporation. The background investigation I am authorizing may require information contained herein and acquired during the investigation to be disclosed to third parties, including credit-reporting businesses and State and local licensing agencies. I hereby authorize and give my consent to such disclosures. NOTE: Management official means any shareholder, employee, or partner who controls a company and any individual who directs the day-to-day operations of a company. With respect to a partnership whose management committee or executive committee has responsibility for the day-to-day operations of the partnership, management official means only a member of such committee but, if no such committee exists, management official means each of the general partners. (12 U.S.C. § 366.2(I))
20. NAME OF MANAGEMENT OFFICIAL COMPLETING FORM (Type or print)			21. TITLE
     			     
22. SIGNATURE (Sign in Ink)			23. DATE
			     

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C §§ 1819, 1820(a), 1822(f); Executive Order 9397; and 12 C.F.R. Part 366.  The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC.  The information you provide may be furnished to third parties, including law enforcement authorities, as authorized by law, or used according to any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records.   Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC.

FDIC 1600/07 (8-15) Page 1 (See Page 2 for the Privacy Act Statement and Estimated Reporting Burden)