INV 100- July 2017 Non-Substantive Update- Mocked Up

FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM

Form Approved
OMB No. 3206-0259

Instructions: Use of this form is optional. You may use any written format for a Freedom of Information (FOIA)
or Privacy Act (PA) Request as long as it contains a description of the information you are requesting and
sufficient personally identifying data when required. Failure to provide the required information may result in
no action being taken on the request. Submit completed forms via fax, mail, or e-mail as scanned attachments.
If submitting via e-mail, you should ensure that the security of your e-mail system is adequate for transmitting
sensitive information before choosing to transmit your request, which contains your personally identifiable
information. Mail: OPM-Federal Investigative Services; ATTN: FOI/PA office, 1137 Branchton Road, P.O. Box 618,
Boyers, PA 16018. Fax: (724) 794-4590. e-Mail: [email protected].

1. Type of Request - (This section must be completed.)
PA/FOIA Request:
I request my own records. (Requester must complete sections 2, 3, 4, 5, and 7.)
FOIA Request:
I am making a request for records about someone or something other than myself.
(Requester must complete sections 2, 3, 7, and 8.)
PA Amendment Request:
I wish to amend my own records. In accordance with 5 C.F.R. § 297.301, the burden of proof rests with the record subject to illustrate
how his/her record is not accurate, timely, relevant, or complete. Requesters should attach additional material to this form.
(Requester must complete sections 2, 4, 5, and 7.)

2. Requester Information - (This section must be completed.)
Full Name:
Street Address:
City:

State:

Zip Code:

Country:

Preferred Delivery Method:

Secure e-Mail*

e-Mail Address:

Hardcopy Mail

Optional:

Telephone Number:

*A secure e-mail ensures that the information being sent to you is encrypted and therefore cannot be intercepted and read. Many widely used e-mail providers
accept this type of file. If your e-mail provider prohibits secure e-mails you will be notified to register with the OPM server. This registration process will
authenticate your identity and will allow the e-mail to be delivered directly to you.

3. Records Requested (Select One)
Standard Form Only (SF86, 85P, or 85)

Most Recent Investigation, including Standard Form

All Investigations and Standard Forms

Other (Specify in the box below) - Attach a separate page if you need more space than
provided below.

U.S. Office of Personnel Management
Federal Investigative Services

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INV 100
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Form Approved
OMB No. 3206-0259

4. Requester's Identifying Information - (Complete this section only if you are making a request for records about yourself.)
Social Security Number:

Date of Birth: (MM/DD/YYYY)

City of Birth:

State of Birth:

Country of Birth:

5. Identity Source Documents - (Copies of two identity source documents must be submitted along with this form.)
Examples of acceptable identity source documents are provided on the OPM-Federal Investigative Services FOIA/PA web page:
https://www.opm.gov/investigations/freedom-of-information-and-privacy-act-requests/
Copies of two identity source documents are attached.

6. Optional: Authorization to Release Information to a Third Party.
By completing this section, you authorize information relating to you to be released to another person, such as a family member or legal
counsel. Please note, if you choose to have your records sent to a third party, you will not be furnished a duplicate copy. Pursuant to 5 U.S.C.
§ 552a(b), I authorize the United States Office of Personnel Management's, Federal Investigative Services to release my records (defined above) to:
Full Name:

Mailing Address:

7. Verification of Requester's Identity - (Complete this section only if you are making a request for records about yourself.)
I declare under the penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and I am the person
named in Section 2. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more
than $10,000, or by imprisonment for not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is
punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.

Handwritten Signature: _______________________________________

Date:

8. Complete this section only if you are requesting records about someone or something other than yourself.
In the box below, you may wish to provide information about yourself and the purpose of your request to help us determine your fee
category. While FOIA does not require a requester to state the purpose of a request, fees may be reduced based on the nature of the
requester or purpose of the request. Fees for searching, copying, and processing records in this category may be levied in accordance with
OPM's regulations at 5 C.F.R. § 294.109. If you are asking for a waiver or reduction of fees, you can also use this box to provide an
explanation. Attach a separate page if you need more space than provided below.

I agree to pay all applicable fees.

I agree to pay up to a specific amount for fees.

Specify the amount

I request a waiver or reduction of fees because I am (check all options listed below that apply):
Affiliated with an educational or noncommercial scientific institution and this request is not for commercial use.
A representative of the news media and this request is part of a news dissemination function and not for commercial use.
Requesting the information in order to contribute significantly to the public understanding of the operations or activities
of the government and I do not primarily have a commercial interest in the information.

U.S. Office of Personnel Management
Federal Investigative Services

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Print Form

INV 100
Sept 2015

FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM
Privacy Routine Use and Disclosure Information

Form Approved
OMB No. 3206-0259

Privacy Act Statement. Information provided by a requester will be used to locate and provide the requester responsive records pursuant to the Freedom of
Information Act (5 U.S.C. § 552), and/or the Privacy Act of 1974 (5 U.S.C. § 552a). Authority to collect this information is contained in 5 U.S.C. § 552, 5 U.S.C. § 552a,
5 C.F.R. § 297.201(b). The purpose of the collection is to enable the United States Office of Personnel Management (OPM) Federal Investigative Services to locate
applicable records and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Failure to provide the required information
may result in no action being taken on the request.
Routine Uses. The information collected on this form will primarily be used to comply with requests for information under Title 5 U.S. Code 552 and 552a. Routine
uses of the records include:
To disclose information to the Office of Management and Budget at any stage in the legislative coordination and clearance process in connection with private
relief legislation as set forth in OMB Circular No. A-19.
To disclose information to an agency, subject to law, rule, or regulation enforced by OPM having been found in violation of such law, rule, or regulation, in
order to achieve compliance with OPM instructions.
To disclose information to Federal agencies in order to obtain advice and recommendations concerning matters on which the agency has specialized
experience or particular competence, for use by OPM in making required determinations under the Freedom of Information Act or the Privacy Act of 1974.
To disclose information to any source from which additional information is requested (to the extent necessary to identify the individual, inform the source of
the purpose of the request, and to identify the type of information requested), where necessary to obtain information relevant to an OPM decision concerning
a Privacy or Freedom of Information Act request.
To disclose to the Federal agency involved, an OPM decision on an appeal from an initial denial of a request involving OPM-controlled records.
To disclose pertinent information to the appropriate Federal, State, or local agency 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.
To provide information to a congressional office from the record of an individual in response to an inquiry from that congressional office made at the request
of that individual.
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.
To disclose information to the National Archives and Records Administration for use in records management inspections.
By OPM in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and
maintained, or for related workforce studies. While published studies do not contain individual identifiers, in some instances the selection of elements of data
included in the study may be structured in such a way as to make the data individually identifiable by inference.
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.
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.
To disclose information to the Equal Employment Opportunity Commission when requested in connection with investigations into alleged or possible
discrimination practices in the Federal sector, compliance by Federal agencies with the Uniform Guidelines on Employee Selection Procedures or other
functions vested in the Commission and to otherwise ensure compliance with the provisions of 5 U.S.C. 7201.
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.
Information Regarding Disclosure of your Social Security Number (SSN) under Public Law 93-579, Section 7 (b). Solicitation of SSNs by OPM is authorized
under the provisions of Executive Order 9397, dated November 22, 1943. Providing your social security number is voluntary. You are asked to provide your social
security number only to facilitate the identification of records relating to you. Without your social security number, OPM may be unable to locate records pertaining
to you. The use of SSNs is necessary because of the large number of Federal employees, contractors, civilians and military personnel who have identical names and/
or birth date and whose identities can only be distinguished by their SSNs.
Public Burden Statement. Public burden reporting for this collection of information is estimated to vary from 5 to 15 minutes with an average of 5 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of
information. Send comments regarding the accuracy of this burden estimation and any suggestions for reducing the burden to: U.S. Office of Personnel
Management, Federal Investigative Services, Attn: OBM Number (3206-0259), 1900 E. Street NW, Washington, DC 20415-7900.

U.S. Office of Personnel Management
Federal Investigative Services

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Sept 2015