Form ATF F 8620.65 ATF F 8620.65 Request for ATF Background Investigation Information

OMB NO: 1140-0105 (xx/xx/xxxx)

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Request for ATF Background Investigation
Information

The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), Personnel Security Division (PSD), has received your background investigation information
inquiry. In order for the PSD staff to process your request, the below information must be provided. Please complete this form. Once completed, scan and
email it to [email protected]. If this request is being made by a State or local agency, a copy of an authorization for release of information signed by
the subject of the investigation and a copy of an official request for the information on agency letterhead must accompany this completed form.
Last Name:

First Name:

Subject’s Information
Middle Name:

Suffix:

Last Four Digits of SSN:

Other Names Used (include maiden and former names):
Requesting Agency Information
Date of Request:

Name of Agency Requesting Background Investigation:

Title of Position for which Subject is Applying:

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Reason for Requesting Background Investigation (employment, reciprocity, etc.):

Agency Point of Contact (POC) (name, telephone number and e-mail address):
Preferred Method of Receiving Copy of Background Investigation:
Overnight Delivery (FedEx, DHL, etc.)

In Person Pick-Up

*OPM Portal

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*Provide the OPM account holder’s name (If the POC does not have an OPM account, provide the name and email address of another agency
representative who is authorized to receive the requested information through the OPM Portal.):

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Agency Address to Forward Copies of Background Investigation Information:

Requestor Certification

Federal Agency’s Certification. This request for information is being made in connection with the hiring or continued employment of an employee
or contractor; the conduct of a suitability or security investigation of an employee or contractor; or the granting, renewal, suspension, or revocation
of a security clearance, to the extent that the information is relevant and necessary to the hiring agency’s decision.
State and Local (including the District of Columbia) Law Enforcement or Detention Agency Certification. This request for information is being
made in connection with the hiring or continued employment of an employee or contractor, where the employee or contractor would occupy or
occupies a position of public trust as a law enforcement officer or detention officer having direct contact with the public or with prisoners or
detainees, to the extent that the information is relevant and necessary to the recipient agency’s decision.
Date of Request: Requestor’s Certification (signature):

Requestor’s Name (please print):

Date of Response:

Requestor’s Title:

PSD Official Use Only
PSD Representative Providing the Background Investigation Information:

ATF Form 8620.65
Revised ( )

Privacy Act Statement
Solicitation of this information is made pursuant to Executive Orders 13764 and 12968. ATF collects and disseminates background investigation records
in accordance with Internal Security Record System – Justice/ATF-006 and is subject to all of the published routine uses of that system of records. ATF
background investigation records may be disclosed to other Federal government agencies in connection with hiring or continued employment of an
employee or contractor. ATF may also release background investigation records to State or local agencies (including the District of Columbia) when the
requesting agency is seeking to staff a law enforcement officer position. The submission of this form documents the official request received from another
agency for an individual’s ATF background investigation record and ATF’s authorized disclosure of the information.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used by ATF to document an official request
received from another agency for an ATF background investigation record. The appropriate ATF office (Personnel Security Division) will maintain a
copy of this form. It will be used to document the authorized disclosure of the background investigation information.
The estimated average burden associated with this collection of information is 5 minutes per respondent, depending on individual circumstances.
Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management
Officer, Resource Management Staff, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.

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An Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information that does not display a currently valid OMB
control number.

ATF Form 8620. 65
Revised ( )