Sf-85p

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR
PUBLIC TRUST 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 21, 25, and 27, however, neither your truthful responses
nor information derived from those responses will be used as evidence
against you in a subsequent criminal proceeding.
Note: If you complete the SF 85P, an Authorization for Release of Medical
Information Pursuant to the Health Insurance Portability and Accountability
Act (HIPAA) will be provided to you only in the event information arises in an
investigation that requires further inquiry for resolution, and only to resolve
such issues. This release authorizes an investigator to ask your health
practitioner(s) only the questions specified on the release concerning mental
health consultations of which the practitioner might be aware. If you are
completing the SF 85P with the supplemental SF 85P-S, this release will be
provided to you if you respond "yes" to the question regarding Your Medical
Record. You may also be asked to complete a specific release if more
detailed information is needed from your provider.

Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting
background investigations and reinvestigations of persons under
consideration for, or retention of, public trust positions as defined in 5 CFR
731. 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 duties to be
performed by an employee of a contractor are equivalent to the duties
performed by an employee in a public trust position. For applicants, this form
is to be used only after a conditional offer of employment has been made.
This form is not to be used for National Security sensitive positions.
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 public trust
position or your ability to obtain or retain Federal or contract employment, 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 a public trust 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, or
prosecution.
This form is a permanent document that may be used as the basis for future
investigations, 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 85P questionnaires.
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.

Page 1

Form approved:
OMB No. 3206 0258

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, 13764, 10577,
13467, and 13488; sections 3301, 3302, 7301, and 9101 of title 5, United
States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal
Regulations (CFR), and Federal information processing standards.
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.
Your spouse's SSN is needed solely to allow the investigative service
provider to make inquiries regarding whether there is relevant conduct on
your part as a result of your relationship with your spouse. Your spouse is not
subject of the investigation.

The Investigative Process
Background investigations for public trust 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 and your Declaration for Federal Employment (OF 306) 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 public trust
position or your ability to obtain Federal or contract employment. To avoid
such delays, you must 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, falsification,
misrepresentation, and any other behavior, activities, or associations that
tend to demonstrate a person is not reliable, trustworthy, or loyal.
After a suitability /fitness determination is made, you may also be subject to
continuous vetting which may include periodic reinvestigations to ensure your
continuing suitability for employment.

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.
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 documents; (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.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

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 drop down feature.

4.

When entering a U.S. address or location, select the state or territory from
the "States" drop down list that will be provided. For locations outside of
the U.S. and its territories, select the country in the "Country" drop down
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.

Office of Personnel Management (OPM) Routine Uses
The Privacy Act routine uses of agencies conducting or requesting
investigations, or with authorized custody over your investigative information,
commonly include some or all of the following:
a.

Final Determination on Your Suitability
Final determination on your suitability for a public trust position is the
responsibility of the Office of Personnel Management or the Federal agency
that requested your investigation. You may be provided the opportunity to
explain, refute, or clarify any information before a final decision is made. 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 making determinations of suitability for a public trust position.

c.

Disclosure Information
The information you provide is for the purpose of investigating you for a
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.

Page 2

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.
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 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.
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.

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, 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 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.

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.

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 numbers (01-12) to indicate months. For example, July
29,1968, should be written as 07/29/1968. 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 “Estimate” box.

Form approved:
OMB No. 3206 0258

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.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

k.

l.

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

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.
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.
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 5U.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-sector EEO complaint.
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.

Page 3

Form approved:
OMB No. 3206 0258

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
counter terrorism officials to fulfill their responsibilities under applicable
Federal law and policy, including but not limited to E.O. 12333, 13587and
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 man made 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 the requesting agency’s decision on the matter.

Public Burden Information
Public burden reporting for this collection of information is estimated
toaverage155minutesperresponse,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 OPM Forms
Officer, U.S. Office of Personnel Management, Attn: OMB Number 3206-0258,
1900 E Street, N.W., Washington, DC 20415. The OMB clearance number,
3206-0258, is currently valid. OPM may not collect this information, and you
are not required to respond, unless this number is displayed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS
LOCATION CODES

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia

AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA

Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland

HI
ID
IL
IN
IA
KS
KY
LA
ME
MD

Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey

MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ

New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina

NM
NY
NC
ND
OH
OK
OR
PA
RI
SC

South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

American Samoa
Baker Island
Guam
Howland Island
Jarvis Island

AS
FQ
GU
HQ
DQ

Johnson Atoll
Kingman Reef
Marshall Islands
Micronesia, Federated
States

JQ
KQ
MH
FM

Midway Islands
Navassa Island
Northern Mariana Islands
Palau

MQ
BQ
MP
PW

Palmyra Atoll
Puerto Rico
Virgin Islands, United
States

LQ
PR
VI

Wake Island
APO/FPO America
APO/FPO Europe
APO/FPO Pacific

WQ
AA
AE
AP

AGENCY USE BLOCK "AUB"

Case Number:

Codes: (FIPC CODES)

Investigating agency user only

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 Risk level

F Date of action (Month/Day/Year)

H Position code

G Geographic location

K Location of Official Personnel Folder

None

L SOI (Security Office Identifier)

NPRC
M Location of Security Folder

N IPAC

O TAS

At SON
e-OPF
None
NPI

E Nature of action code
J SON (Submitting Office Number)

I Position title

Other Other address/Web address of e-OPF

Zip Code

At SOI
e-OPF Other address/Web address of e-OPF Zip Code
Other
P Obligating document number
Q BETC
S Investigative requirement

R Accounting data and/or Agency case number

Initial
Reinvestigation

T Requesting Official - Name

Title

Signature

Email address

Telephone number (Include Ext.)

U Secondary Requesting Official - Name

Title
Telephone number (Include Ext.)

Email address
W Deployment/PCS (if imminent)

From (Month/Day/Year)

Est.

Point of contact at location

Telephone number (Include Ext.)

To (Month/Day/Year)

Page 4

V Applicant affiliation

FED CIV
MIL

CON
Other

Reason(s) for temporary duty assignment or PCS
Estimated
Permanent Relocation
Address/Unit/Duty location (Include City or Post Name)

Agency Special Instructions for the Investigative Service Provider.

Commercial and Government Entity (CAGE) Code

Date (Month/Day/Year)

Contract Number

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

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), or removal and debarment from Federal
Service.

YES

NO

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.
First Name
Suffix
Last Name
Middle Name

Section 2 - Date of Birth

Section 3 - Place of Birth

Provide your date of
birth. (Month/Day/Year)

Provide your place of birth.
City

State

County

Country (Required)

Est.
Section 4 - Social Security Number
Provide your U.S. Social Security Number.
Not applicable
Section 5 - Other Names Used
Have you used any other names?

YES

NO (If NO, proceed to Section 6)

Complete the following if you have responded 'Yes' to having used other names.
Provide your other name(s) used and the period of time you used it/them [for example: your maiden name, name(s) by a former marriage, former name(s),
alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No
Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Provide other name used

#1

First name

Last name
From (Month/Year)

To (Month/Year)
Est.

Present

Maiden name?
YES

Est.

Suffix

Middle name

NO

Provide the reason(s) why the name changed

Provide other name used

#2

First name

Last name
From (Month/Year)

To (Month/Year)
Est.

Present

Maiden name?
YES

Est.

Suffix

Middle name
Provide the reason(s) why the name changed

NO

Provide other name used

#3

First name

Last name
From (Month/Year)

To (Month/Year)
Est.

Present

Maiden name?
YES

Est.

Suffix

Middle name
Provide the reason(s) why the name changed

NO

Provide other name used

#4

First name

Last name
From (Month/Year)

To (Month/Year)
Est.

Present

Maiden name?

Est.

Suffix

Middle name

YES

Provide the reason(s) why the name changed

NO

Section 6 - Your Identifying Information
Provide your identifying information.
Weight (in pounds)
Height
(feet)

Hair color

(inches)

Enter your Social Security Number before going to the next page
Page 5

Eye color

Sex

Female
Male

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

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.
Home e-mail address

Work e-mail address
Day

International or DSN phone number
Home telephone number

Night

Extension

International or DSN phone number
Work telephone number

Extension

Both

Day

International or DSN phone number

Night Mobile/Cell telephone number Extension
Both

Day
Night
Both

Section 8 - U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
YES

NO (If NO, proceed to Section 9)

Provide the following information for the most recent U.S. passport you currently possess.
Passport number
Issue date (Month/Day/Year) Expiration date (Month/Day/Year) Click HERE for U.S. State Department passport help
http://travel.state.gov/passport
Est.
Est.
Provide the name in which passport was first issued.
First name
Last name

Suffix

Middle name

Section 9 - Citizenship
Select the box that reflects your current citizenship status.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
(Proceed to Section 10)

I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.
(Complete 9.1)

I am a derived U.S. citizen. (Complete 9.3)
I am not a U.S. citizen. (Complete 9.4)

I am a naturalized U.S. citizen. (Complete 9.2)
9.1 Complete the following if 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.
FS 240

DS 1350

FS 545

Other (Provide explanation)

Provide document number for U.S. citizen born abroad.

Provide the date the document was issued. (Month/Day/Year)
Est.

Provide the name in which document was issued.
First name
Last name

Provide your citizenship certificate number.

Suffix

Middle name

Provide the date the certificate was issued. (Month/Day/Year)
Est.

Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)
State
Country
City
Provide the name in which the certificate was issued.
First name
Last name
Were you born on a U.S. military installation?
YES

Provide the name of the base.

NO (If NO, proceed to Section 10)

Enter your Social Security Number before going to the next page
Page 6

Middle name

Suffix

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 9 - Citizenship - (Continued)
9.2 Complete the following if you answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S.

Provide the location of entry into the U.S.
City

(Month/Day/Year)

State

Est.
Provide country(ies) of prior citizenship.
#1 Country

#2 Country

Do/did you have a U.S. alien registration number?
YES
NO

Provide your U.S. alien registration number on Certificate of
Naturalization - utilize USCIS, CIS, or INS registration, I-551, I-766.

Provide your Certificate of Naturalization number (N550 or N570).
Provide the name of the court that issued the
Certificate of Naturalization.

Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)

Provide the address of the court that issued the Certificate of Naturalization.
State
Street
City

Provide the name in which the Certificate of Naturalization was issued.
First name
Last name

Middle name

Est.

Zip Code

Suffix

Provide the basis of naturalization.
Based on my own individual naturalization application
Other (Provide explanation)
9.3 Complete the following if you answered that you are a derived U.S. citizen.
Provide your alien registration number (on Certificate of
Citizenship — utilize USCIS, CIS or INS registration number)

Provide your Permanent Resident Card
number (I-551)

Provide the name in which the document was issued.
First name
Last name
Provide the date document was issued (Month/Day/Year)
Est.

Provide your Certificate of Citizenship
number (N560 or N561)

Middle name

Suffix

Provide the basis of derived citizenship.
By operation of law through my U.S. citizen parent
Other (Provide explanation)

9.4 Complete the following if you answered that you are not a U.S. citizen.
Provide your residence status.

Provide your date of entry in the U.S. (Month/Day/Year)
Est.

Provide your country(ies) of citizenship.
#1 Country

#2 Country

Provide your place of entry in the U.S.
City

State

Provide your alien registration
number (I-551, I-766)

Provide document expiration
date (I-766 ONLY) (Month/Day/Year)
Est.

Provide type of document issued. (I-94, U.S. Visa - red foil number, I-20, DS-2019, etc.)
I-94
U.S. Visa (red foil number)
I-20
DS-2019
Other (Provide explanation)
Provide document number.

Provide the date document was issued

(Month/Day/Year)

Provide document expiration date. (Month/Day/Year)

Est.
Provide the name in which the document was issued.
First name
Last name

Enter your Social Security Number before going to the next page
Page 7

Est.
Middle name

Suffix

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information
10.1 Do you now or have you EVER held dual/multiple citizenships?

YES

NO (If NO, proceed to 10.2)

Complete the following if you answered 'Yes' to having EVER held dual/multiple citizenships.
Entry #1
Provide country of citizenship.
How did you acquire this non-U.S. citizenship you now have or previously had?

During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
From Date (Month/Year)
To Date (Month/Year)
Present
Est.

Est.

Do you currently hold citizenship with this country?
YES

NO

Provide explanation:

Entry #2
Provide country of citizenship.
How did you acquire this non-U.S. citizenship you now have or previously had?

During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
From Date (Month/Year)
To Date (Month/Year)
Present
Est.

Est.

Do you currently hold citizenship with this country?
YES

NO

Provide explanation:

10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?

YES

NO (If NO, proceed to Section 11)

Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #1
Provide the date the passport (or identity card) was issued. (Month/Day/Year)

Provide the country in which the passport (or identity card) was issued.

Est.
Provide the place the passport (or identity card) was issued.
City

Country

Provide the name in which passport (or identity card) was issued.
First name
Last name

Middle name

Suffix

Provide the passport (or identity card) expiration date. (Month/Day/Year)

Provide the passport (or identity card) number.

Est.
Have you EVER used this passport (or identity card) for foreign travel?
YES

NO

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country

From date (Month/Year)

To date (Month/Year)

#1

Est.

Est.

Present

#2

Est.

Est.

Present

#3

Est.

Est.

Present

#4

Est.

Est.

Present

#5

Est.

Est.

Present

#6

Est.

Est.

Present

Enter your Social Security Number before going to the next page
Page 8

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued)
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #2
Provide the date the passport (or identity card) was issued. (Month/Day/Year)

Provide the country in which the passport (or identity card) was issued.

Est.
Provide the place the passport (or identity card) was issued.
City

Country

Provide the name in which passport (or identity card) was issued.
First name
Last name

Middle name

Suffix

Provide the passport (or identity card) expiration date. (Month/Day/Year)

Provide the passport (or identity card) number.

Est.
Have you EVER used this passport (or identity card) for foreign travel?
YES

NO

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country

From date (Month/Year)

To date (Month/Year)

#1

Est.

Est.

Present

#2

Est.

Est.

Present

#3

Est.

Est.

Present

#4

Est.

Est.

Present

#5

Est.

Est.

Present

#6

Est.

Est.

Present

Enter your Social Security Number before going to the next page
Page 9

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 11 - Where You Have Lived
List the places where you have lived beginning with your present residence and working back 7 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.
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 periods of residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for residence.
Enter residence information.
Entry #1
Provide dates of residence.
From (Month/Year)

Is/was this residence:
To (Month/Year)

Est.

Present

Owned by you

Rented or leased by you

Est.

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Street
State
Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
First name
Last name
Middle name

Provide date of last contact.
(Month/Year)

Suffix

Est.
Provide your relationship to this person (Select all that apply).
Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

Provide the following contact information for this person.
I don't know
International or DSN phone number
Evening telephone number
Extension

I don't know

I don't know

International or DSN phone number
Daytime telephone number
Extension

International or DSN phone number
Cell/mobile telephone number
Extension

Provide e-mail address for this person.
I don't know
Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does the person who knew you have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 10

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 11 - Where You Have Lived - (Continued)
Enter residence information.
Entry #2
Provide dates of residence.
From (Month/Year)

Is/was this residence:
To (Month/Year)

Est.

Present

Owned by you

Rented or leased by you

Est.

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Street
State
Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
First name
Last name
Middle name

Provide date of last contact.
(Month/Year)

Suffix

Est.
Provide your relationship to this person (Select all that apply).
Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

Provide the following contact information for this person.
I don't know
International or DSN phone number
Evening telephone number
Extension

I don't know

I don't know

International or DSN phone number
Daytime telephone number
Extension

International or DSN phone number
Cell/mobile telephone number
Extension

Provide e-mail address for this person.
I don't know
Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does the person who knew you have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 11

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 11 - Where You Have Lived - (Continued)
Enter residence information.
Entry #3
Provide dates of residence.
From (Month/Year)

Is/was this residence:
To (Month/Year)

Est.

Present

Owned by you

Rented or leased by you

Est.

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Street
State
Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
First name
Last name
Middle name

Provide date of last contact.
(Month/Year)

Suffix

Est.
Provide your relationship to this person (Select all that apply).
Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

Provide the following contact information for this person.
I don't know
International or DSN phone number
Evening telephone number
Extension

I don't know

I don't know

International or DSN phone number
Daytime telephone number
Extension

International or DSN phone number
Cell/mobile telephone number
Extension

Provide e-mail address for this person.
I don't know
Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does the person who knew you have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 12

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 11 - Where You Have Lived - (Continued)
Enter residence information.
Entry #4
Provide dates of residence.
From (Month/Year)

Is/was this residence:
To (Month/Year)

Est.

Present

Owned by you

Rented or leased by you

Est.

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Street
State
Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
First name
Last name
Middle name

Provide date of last contact.
(Month/Year)

Suffix

Est.
Provide your relationship to this person (Select all that apply).
Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

Provide the following contact information for this person.
I don't know
International or DSN phone number
Evening telephone number
Extension

I don't know

I don't know

International or DSN phone number
Daytime telephone number
Extension

International or DSN phone number
Cell/mobile telephone number
Extension

Provide e-mail address for this person.
I don't know
Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does the person who knew you have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 13

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 12 - Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.
(a) Have you attended any schools in the last 7 years?
YES

(b) Have you received a degree or diploma more than 7 years ago?

NO

YES

Entry #1
Provide the dates of attendance.
From Date (Month/Year)

Select the most appropriate below to describe your school.

To Date (Month/Year)

Est.

NO (If NO to 12(a) and 12(b), proceed to Section 13A)

Present

High School

Vocational/Technical/Trade School

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

Provide the name of the school.
Provide the street address of the school. For correspondence/distance/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 City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)

City

Street

State

Country

Zip 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 education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Provide the name of the person who knows/knew you at school:

First name

Last name

I don't know
Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
City
State
Street
Zip Code
Provide telephone number for this person.
Telephone number
Extension

Provide email address for this person.
I don't know
International or DSN phone number
Day
Night

I don't know

Did you receive a degree/diploma?
YES

NO

Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,
• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

Entry #2
Provide the dates of attendance.
From Date (Month/Year)

To Date (Month/Year)

Est.

Date awarded

Other degree/diploma

(Month/Year)

Est.

Select the most appropriate below to describe your school.
Present

High School

Vocational/Technical/Trade School

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

Provide the name of the school.
Provide the street address of the school. For correspondence/distance/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 City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

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 education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Provide the name of the person who knows/knew you at school:

Last name

I don't know

Enter your Social Security Number before going to the next page
Page 14

First name

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 12 - Where You Went to School - (Continued)
Entry #2 (Continued)
Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
City
State
Street
Zip Code
Provide telephone number for this person.
Telephone number
Extension

Provide email address for this person.
I don't know
International or DSN phone number
Day
Night

I don't know

Did you receive a degree/diploma?
YES

NO

Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,
• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

Date awarded

Other degree/diploma

(Month/Year)

Est.

Entry #3
Provide the dates of attendance.
From Date (Month/Year)

To Date (Month/Year)

Est.

Select the most appropriate below to describe your school.
Present

High School

Vocational/Technical/Trade School

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

Provide the name of the school.
Provide the street address of the school. For correspondence/distance/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 City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)

City

Street

State

Country

Zip 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 education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know
Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
City
State
Street
Zip Code
Provide telephone number for this person.
Telephone number
Extension

Provide email address for this person.
I don't know
International or DSN phone number
Day
Night

I don't know

Did you receive a degree/diploma?
YES

NO

Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,
• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

Enter your Social Security Number before going to the next page
Page 15

Other degree/diploma

Date awarded
(Month/Year)

Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 12 - Where You Went to School - (Continued)
Entry #4
Provide the dates of attendance.
From Date (Month/Year)

To Date (Month/Year)

Est.

Select the most appropriate below to describe your school.
Present

High School

Vocational/Technical/Trade School

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

Provide the name of the school.
Provide the street address of the school. For correspondence/distance/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 City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)

City

Street

State

Country

Zip 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 education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know
Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
City
State
Street
Zip Code
Provide telephone number for this person.
Telephone number
Extension

Provide email address for this person.
I don't know
International or DSN phone number
Day
Night

I don't know

Did you receive a degree/diploma?
YES

NO

Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,
• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

Enter your Social Security Number before going to the next page
Page 16

Other degree/diploma

Date awarded
(Month/Year)

Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 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.
Entry #1
Select your employment activity:
Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

(Complete 13A.2, 13A.5 and 13A.6)

and 13A.6)

and 13A.6)

Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)

Entry #1

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide your assigned duty station during this period.
Provide your most recent rank/position title.

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Telephone number

Extension

International or DSN phone number
Day

Night

Both

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Do you or did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Provide the rank/position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Both

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Do/did your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 17

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #1

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employer.

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

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

From date (Month/Year)

Position Title

To date (Month/Year)
Est.

Est.

Est.

Est.

Est.

Est.

Est.

Est.

Supervisor

(a) Is/was your physical work address different than your employer's address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Country

Zip Code

APO/FPO State Code

Zip Code

Provide the position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Did/does your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 18

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #1

13A.3 Complete the following if employment type is self-employment
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employment.

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Night

(a) Is your physical work address different than your employment address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this address.
Telephone number
Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES

Country

APO/FPO State Code

Zip Code

NO
Provide the name of someone that can verify your self-employment.
First name
Last name
Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this person.
Telephone number
Extension

International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does your self-employment verifier have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 19

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #1

13A.4 Complete the following if employment type is unemployment.
Provide dates of unemployment.
To Date(Month/Year)

From Date (Month/Year)
Est.

Present
Est.

Provide the name of someone that can verify your unemployment activities
and means of support.
First name
Last name

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
Street
City
State
Zip Code
Provide the telephone number for this person.
Verifier telephone number Extension
International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

City or Post Name

Street Address/Unit/Duty Location

(b) Does your unemployment verifier have an APO/FPO address?
Address
YES

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Entry #1

NO
13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Provide the reason for leaving the employment activity.
For this employment have any of the following happened to you in the last seven (7) years?
● 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.
YES
NO (If NO, proceed to 13A.6)

Select your type of incident:

Reason:

Employment departure date

Provide the reason for being fired.

Provide the date you were fired. (Month/Year)

Provide the reason for quitting.

Provide the date you quit after being told you would be
fired. (Month/Year)
Est.

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations
of misconduct. (Month/Year)

Est.

Fired
Quit after being told you would be
fired
Left by mutual agreement following
charges or allegations of misconduct

Est.
Provide the reason(s) for unsatisfactory performance.

Left by mutual agreement following
notice of unsatisfactory performance

Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Est.

Entry #1

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
YES

NO

#1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

Enter your Social Security Number before going to the next page
Page 20

Est.
Est.
Est.
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 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.
Entry #2
Select your employment activity:
Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

(Complete 13A.2, 13A.5 and 13A.6)

and 13A.6)

and 13A.6)

Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)

Entry #2

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide your assigned duty station during this period.
Provide your most recent rank/position title.

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Telephone number

Extension

International or DSN phone number
Day

Night

Both

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Do you or did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Provide the rank/position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Both

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Do/did your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 21

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #2

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employer.

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

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

From date (Month/Year)

Position Title

To date (Month/Year)
Est.

Est.

Est.

Est.

Est.

Est.

Est.

Est.

Supervisor

(a) Is/was your physical work address different than your employer's address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Country

Zip Code

APO/FPO State Code

Zip Code

Provide the position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Did/does your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 22

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #2

13A.3 Complete the following if employment type is self-employment
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employment.

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Night

(a) Is your physical work address different than your employment address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this address.
Telephone number
Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES

Country

APO/FPO State Code

Zip Code

NO
Provide the name of someone that can verify your self-employment.
First name
Last name
Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this person.
Telephone number
Extension

International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does your self-employment verifier have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 23

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #2

13A.4 Complete the following if employment type is unemployment.
Provide dates of unemployment.
From Date (Month/Year)

To Date(Month/Year)
Est.

Present
Est.

Provide the name of someone that can verify your unemployment activities
and means of support.
First name
Last name

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
Street
City
State
Zip Code
Provide the telephone number for this person.
Verifier telephone number Extension
International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

City or Post Name

Street Address/Unit/Duty Location

(b) Does your unemployment verifier have an APO/FPO address?
Address
YES

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Entry #2

NO
13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Provide the reason for leaving the employment activity.
For this employment have any of the following happened to you in the last seven (7) years?
● 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.
YES
NO (If NO, proceed to 13A.6)

Select your type of incident:

Reason:

Employment departure date

Provide the reason for being fired.

Provide the date you were fired. (Month/Year)

Provide the reason for quitting.

Provide the date you quit after being told you would be
fired. (Month/Year)
Est.

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations
of misconduct. (Month/Year)

Est.

Fired
Quit after being told you would be
fired
Left by mutual agreement following
charges or allegations of misconduct

Est.
Provide the reason(s) for unsatisfactory performance.

Left by mutual agreement following
notice of unsatisfactory performance

Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Est.

Entry #2

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
YES

NO

#1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

Enter your Social Security Number before going to the next page
Page 24

Est.
Est.
Est.
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 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.
Entry #3
Select your employment activity:
Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

(Complete 13A.2, 13A.5 and 13A.6)

and 13A.6)

Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6)

13A.6)

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)

Entry #3

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide your assigned duty station during this period.
Provide your most recent rank/position title.

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Telephone number

Extension

International or DSN phone number
Day

Night

Both

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Do you or did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Provide the rank/position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Both

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Do/did your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 25

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #3

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employer.

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

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

From date (Month/Year)

Position Title

To date (Month/Year)
Est.

Est.

Est.

Est.

Est.

Est.

Est.

Est.

Supervisor

(a) Is/was your physical work address different than your employer's address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Country

Zip Code

APO/FPO State Code

Zip Code

Provide the position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Did/does your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 26

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #3

13A.3 Complete the following if employment type is self-employment
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employment.

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Night

(a) Is your physical work address different than your employment address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this address.
Telephone number
Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES

Country

APO/FPO State Code

Zip Code

NO
Provide the name of someone that can verify your self-employment.
First name
Last name
Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this person.
Telephone number
Extension

International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does your self-employment verifier have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 27

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #3

13A.4 Complete the following if employment type is unemployment.
Provide dates of unemployment.
From Date (Month/Year)

To Date(Month/Year)
Est.

Present
Est.

Provide the name of someone that can verify your unemployment activities
and means of support.
First name
Last name

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
Street
City
State
Zip Code
Provide the telephone number for this person.
Verifier telephone number Extension
International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

City or Post Name

Street Address/Unit/Duty Location

(b) Does your unemployment verifier have an APO/FPO address?
Address
YES

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Entry #3

NO
13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Provide the reason for leaving the employment activity.
For this employment have any of the following happened to you in the last seven (7) years?
● 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.
YES
NO (If NO, proceed to 13A.6)

Select your type of incident:

Reason:

Employment departure date

Provide the reason for being fired.

Provide the date you were fired. (Month/Year)

Provide the reason for quitting.

Provide the date you quit after being told you would be
fired. (Month/Year)
Est.

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations
of misconduct. (Month/Year)

Est.

Fired
Quit after being told you would be
fired
Left by mutual agreement following
charges or allegations of misconduct

Est.
Provide the reason(s) for unsatisfactory performance.

Left by mutual agreement following
notice of unsatisfactory performance

Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Est.

Entry #3

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
YES

NO

#1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

Enter your Social Security Number before going to the next page
Page 28

Est.
Est.
Est.
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 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.
Entry #4
Select your employment activity:
Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

(Complete 13A.2, 13A.5 and 13A.6)

and 13A.6)

and 13A.6)

Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)

Entry #4

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide your assigned duty station during this period.
Provide your most recent rank/position title.

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Telephone number

Extension

International or DSN phone number
Day

Night

Both

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Do you or did you have an APO/FPO address while at this location?
Address
YES

State

Country

Zip Code

APO or FPO

APO/FPO State Code

Zip Code

NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Provide the rank/position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Both

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Do/did your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 29

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #4

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employer.

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

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

From date (Month/Year)

Position Title

To date (Month/Year)
Est.

Est.

Est.

Est.

Est.

Est.

Est.

Est.

Supervisor

(a) Is/was your physical work address different than your employer's address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number

Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO
Provide the name of your supervisor.
Provide the email address of your supervisor.

Country

Zip Code

APO/FPO State Code

Zip Code

Provide the position title of your supervisor.
I don't know Provide supervisor's telephone number. Extension

International or DSN phone number
Day

Night

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

(b) Did/does your supervisor have an APO/FPO address while at this location?
APO or FPO
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 30

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #4

13A.3 Complete the following if employment type is self-employment
Provide dates of employment.
From Date

Select the employment status for
this position:

To Date

(Month/Year)

(Month/Year)

Est.

Present

Full-time

Est.

Part-time

Provide most recent position title.
Provide the name of your employment.

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Night

(a) Is your physical work address different than your employment address?
YES

NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this address.
Telephone number
Extension

International or DSN phone number
Day

Night

(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

(b.2) Do you or did you have an APO/FPO address while at this location?
APO or FPO
Address
YES

Country

APO/FPO State Code

Zip Code

NO
Provide the name of someone that can verify your self-employment.
First name
Last name
Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Provide the telephone number for this person.
Telephone number
Extension

International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

(b) Does your self-employment verifier have an APO/FPO address?
Address
YES
NO

Enter your Social Security Number before going to the next page
Page 31

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13A - Employment Activities - (Continued)

Entry #4

13A.4 Complete the following if employment type is unemployment.
Provide dates of unemployment.
From Date (Month/Year)

To Date(Month/Year)
Est.

Present
Est.

Provide the name of someone that can verify your unemployment activities
and means of support.
First name
Last name

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Country
Street
City
State
Zip Code
Provide the telephone number for this person.
Verifier telephone number Extension
International or DSN phone number
Day

Night

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

City or Post Name

Street Address/Unit/Duty Location

(b) Does your unemployment verifier have an APO/FPO address?
Address
YES

State

APO or FPO

Zip Code

Country

APO/FPO State Code

Zip Code

Entry #4

NO
13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Provide the reason for leaving the employment activity.
For this employment have any of the following happened to you in the last seven (7) years?
● 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.
YES
NO (If NO, proceed to 13A.6)

Select your type of incident:

Reason:

Employment departure date

Provide the reason for being fired.

Provide the date you were fired. (Month/Year)

Provide the reason for quitting.

Provide the date you quit after being told you would be
fired. (Month/Year)
Est.

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations
of misconduct. (Month/Year)

Fired

Est.

Quit after being told you would be
fired
Left by mutual agreement following
charges or allegations of misconduct

Est.
Provide the reason(s) for unsatisfactory performance.

Left by mutual agreement following
notice of unsatisfactory performance

Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Est.

Entry #4

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
YES

NO

#1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

Enter your Social Security Number before going to the next page
Page 32

Est.
Est.
Est.
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 13B - Employment Activities - Former Federal Service
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
YES

NO (If NO, proceed to Section 13C)

Complete the following if you selected "Yes" to having former federal civilian employment, excluding military service, NOT indicated previously.
Entry #1
Provide dates of federal civilian employment.
To Date (Month/Year)
From Date (Month/Year)
Est.

Provide the name of the federal agency for
Present which you are/were employed.

Provide your position title.

Est.

Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Entry #2
Provide dates of federal civilian employment.
To Date (Month/Year)
From Date (Month/Year)
Est.

Provide the name of the federal agency for
Present which you are/were employed.

Provide your position title.

Est.

Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Entry #3
Provide dates of federal civilian employment.
To Date (Month/Year)
From Date (Month/Year)

Provide the name of the federal agency for
Present which you are/were employed.

Provide your position title.

Est.
Est.
Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code
Entry #4
Provide dates of federal civilian employment.
To Date (Month/Year)
From Date (Month/Year)

Provide the name of the federal agency for
Present which you are/were employed.

Provide your position title.

Est.
Est.
Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
Country
Street
State
Zip Code

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?
- 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 policy?
YES (If YES, you will be required to add an additional employment in Section 13A)
NO (If NO, proceed to Section 14)
Section 14 - Selective Service Record
Were you born a male after December 31, 1959?
YES

NO (If NO, proceed to Section 15)

Have you registered with the Selective Service System (SSS)?
Yes

Provide registration number:

No

Provide explanation:

I don't know

Provide explanation:

Enter your Social Security Number before going to the next page
Page 33

The Selective Service website, www.sss.gov, can help provide the
registration number for persons who have registered. Note: Selective
Service Number is not your Social Security Number.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 15 - Military History
Have you EVER served in the U.S. Military?
YES

NO (If NO, proceed to 15.2)

15.1(a) Complete the following if you responded 'Yes' to having served in the U.S. Military.
Entry #1
Provide the branch of service you served in.
Army

Air National
Guard

Army National
Guard

Marine Corps

Navy

Coast Guard

State of service, if
National Guard

Officer or enlisted
Not Applicable
Officer

Provide your status
Active Duty

Enlisted

Active Reserve

Air Force

Provide your service number.

Provide your dates of service.
From Date

To Date

(Month/Year)

(Month/Year)

Est.

Inactive Reserve

Present
Est.

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES

NO
Provide the date of
discharge listed

Provide the type of discharge you received:
Honorable
Dishonorable

Under Other than
Honorable Conditions
General

Bad Conduct

(Month/Year)

Other (provide type)

Est.

Provide the reason(s) for the discharge, if discharge is other than Honorable
Entry #2
Provide the branch of service you served in.
Army

Air National
Guard

Army National
Guard

Marine Corps

Navy

Coast Guard

State of service, if
National Guard

Officer or enlisted

Provide your status
Active Duty

Air Force

Active Reserve

Provide your service number.

Not Applicable
Officer
Enlisted

Provide your dates of service.
From Date

To Date

(Month/Year)

Inactive Reserve

(Month/Year)

Est.

Present
Est.

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES

NO

Provide the type of discharge you received:
Honorable
Dishonorable

Under Other than
Honorable Conditions
General

Bad Conduct
Other (provide type)

Provide the reason(s) for the discharge, if discharge is other than Honorable

Enter your Social Security Number before going to the next page
Page 34

Provide the date of
discharge listed
(Month/Year)

Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 15 - Military History - (Continued)
15.1(b) In the last seven (7) years, have you been subject to court martial or other disciplinary procedure
under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135
Court of Inquiry, etc?

YES

NO (If NO proceed to 15.2)

Complete the following if you responded 'Yes' to In the last seven (7) years, have you been subject to court martial or other disciplinary procedure under the
Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.
Entry #1
Provide the date of the court martial or other disciplinary procedure. (Month/Year)
Est.
Provide a description of the Uniform Code of Military Justice (UCMJ)
offense(s) for which you were charged.

Provide the name of the disciplinary procedure, such as Court Martial,
Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.

Provide the description of the military court or other authority in which you
were charged (title of court or convening authority, address, to include city
and state or country if overseas).

Provide the description of the final outcome of the disciplinary procedure,
such as found guilty, found not guilty, fine, reduction in rank,
imprisonment, etc.

Entry #2
Provide the date of the court martial or other disciplinary procedure. (Month/Year)
Est.
Provide a description of the Uniform Code of Military Justice (UCMJ)
offense(s) for which you were charged.

Provide the name of the disciplinary procedure, such as Court Martial,
Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.

Provide the description of the military court or other authority in which you
were charged (title of court or convening authority, address, to include city
and state or country if overseas).

Provide the description of the final outcome of the disciplinary procedure,
such as found guilty, found not guilty, fine, reduction in rank,
imprisonment, etc.

Enter your Social Security Number before going to the next page
Page 35

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 15 - Military History - (Continued)
15.2

Have you 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?

YES

NO (If NO, proceed to Section 16)

Complete the following if 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.
Entry #1
During your foreign service, which organization were you serving under?
Military (Army, Navy, Air Force, Marines, etc.), Specify
Intelligence Service

Security Forces

Diplomatic Service

Militia

Other Government Agency, Specify
Other Defense Forces, Specify
Provide the name of the foreign organization.

Provide the name of the country.

Provide your period of service.
From Date (Month/Year)
To Date (Month/Year)
Est.

Provide your highest position/rank held.

Present
Est.

Provide division/department/office in which you served.

Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.

Entry #2
During your foreign service, which organization were you serving under?
Military (Army, Navy, Air Force, Marines, etc.), Specify
Intelligence Service

Security Forces

Diplomatic Service

Militia

Other Government Agency, Specify
Other Defense Forces, Specify
Provide the name of the foreign organization.

Provide the name of the country.

Provide your highest position/rank held.

Provide your period of service.
From Date (Month/Year)
To Date (Month/Year)
Est.

Page 36

Est.

Provide division/department/office in which you served.

Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.

Enter your Social Security Number before going to the next page

Present

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 16 - People Who Know You Well
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.
Entry #1
Provide dates known.
From Date (Month/Year)

To Date (Month/Year)
Est.

Present

Provide relationship to you. (Select all that apply)
Neighbor
Work associate
Other (Provide explanation)

Est.

Provide full name.
Last name

Friend

Schoolmate

First name

Provide e-mail address for this person.

Provide telephone number for
this person.

I don't know
Extension

Provide rank/title

I don't know

International or DSN Provide mobile/cell telephone
number for this person.
phone number
Day

Suffix

Middle name

Not applicable
I don't know
Extension

Night

International or DSN
phone number
Day

Night

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
Street
City
State
Zip Code
Entry #2
Provide dates known.
From Date (Month/Year)

To Date (Month/Year)
Est.

Present

Provide relationship to you. (Select all that apply)
Neighbor
Work associate
Other (Provide explanation)

Est.

Provide full name.
Last name

Friend

Schoolmate

First name

Provide e-mail address for this person.

Provide telephone number for
this person.

I don't know
Extension

Provide rank/title

I don't know

International or DSN Provide mobile/cell telephone
number for this person.
phone number
Day

Suffix

Middle name

Not applicable
I don't know
Extension

Night

International or DSN
phone number
Day

Night

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
Street
City
State
Zip Code
Entry #3
Provide dates known.
From Date (Month/Year)

To Date (Month/Year)
Est.

Present
Est.

Provide full name.
Last name

Friend

Schoolmate

First name

Provide e-mail address for this person.

Provide telephone number for
this person.

Provide relationship to you. (Select all that apply)
Neighbor
Work associate
Other (Provide explanation)

I don't know
Extension

I don't know

Provide rank/title

International or DSN Provide mobile/cell telephone
number for this person.
phone number
Day

Not applicable
I don't know
Extension

Night

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
Street
State
City
Zip Code

Enter your Social Security Number before going to the next page
Page 37

Suffix

Middle name

International or DSN
phone number
Day

Night

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 17 - Marital/Relationship Status
Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic partnership:
Never entered in a civil marriage, legally recognized civil union, or legally
Separated (Complete 17.1 and 17.3)
recognized domestic partnership (Complete 17.3)
Annulled (Complete 17.2 and 17.3)
Currently in a civil marriage, legally recognized civil union, or legally
recognized domestic partnership (Complete 17.1 and 17.3)

Divorced/Dissolved (Complete 17.2 and 17.3)
Widowed (Complete 17.2 and 17.3)

17.1 Complete the following if you selected currently in a civil marriage, 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 name

First name

Middle name

Suffix

Provide the date of birth.
(Month/Day/Year)

Est.
Provide place of birth.
City

County

State

Country (required)

If the person is foreign born, provide one type of documentation that he or she possesses and the document number.
FS 240 or 545

U.S. Passport (current or most recent)

DS 1350

Alien Registration

None (Provide explanation)

Other (Provide explanation)
U.S. Certificate of
Citizenship

U.S. Certificate of Naturalization
Provide U.S. Social Security Number.

Provide document number.

Not applicable
Provide other names used (such as maiden name, names by other marriages, civil marriages, legally recognized
civil unions, or legally recognized domestic partnerships, nicknames, etc., and provide dates used for each name).
#1 Last name
Maiden name?

First name
From (Month/Year)

To (Month/Year)
Est.

#2 Last name
Maiden name?

To (Month/Year)
Est.

#3 Last name
Maiden name?

Est.

Maiden name?

Suffix

Middle name

Suffix

Present
Est.

To (Month/Year)
Est.

Provide country(ies) of citizenship.
Country #1

Middle name

Present

First name
From (Month/Year)

Suffix

Est.

To (Month/Year)

#4 Last name

Middle name

Present

First name
From (Month/Year)

Suffix

Est.
First name

From (Month/Year)

Not applicable

Middle name

Country #2

Present
Est.
Provide date when you entered into your civil
marriage, civil union, or domestic partnership. (Month/Day/Year)
Est.

Enter your Social Security Number before going to the next page
Page 38

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 17 - Marital/Relationship Status - (Continued)
17.1 Complete the following if you selected currently in a civil marriage, 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. (Continued)
Provide location. (Provide City and Country if outside the United States; otherwise, provide City or County and State.)
County
Country
City
State
Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Street
State
Zip Code
Provide telephone number.

Extension

Day

Use my current telephone number

Night

International or DSN phone number

Does the person have an APO/FPO address within the United States?
Address
YES
NO

APO or FPO

Country

Use my current address

Provide email address.

APO/FPO State Code

Zip Code

If you have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/
fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
City or Post Name
Street Address/Unit/Duty Location
State
Zip Code
Country
Are you separated?
YES
NO

Provide date of separation.
(Month/Day/Year)

If legally separated, provide the location of the record.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code

Est.

Enter your Social Security Number before going to the next page
Page 39

Not Applicable

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 17 - Marital/Relationship Status - (Continued)
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?

YES

NO

17.2 Complete the following if you selected divorced/dissolved, annulled, or widowed. Provide information about any person from whom you are divorced/
dissolved, annulled, or widowed.
Entry #1
Provide the full name.
Last name

Middle name

First name

Provide the place of birth.
City

State

Provide the country(ies) of citizenship.
Country #1

Zip Code

Provide the date of birth.
(Month/Day/Year)

Suffix

Est.

Country (Required)

Country #2

Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)
Est.
Provide the location. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
Country
City
State
Provide the status.
Divorced/Dissolved

Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)
Widowed

Annulled

Est.

Provide where the record of divorce/dissolution or annulment is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code
Is this person deceased?
YES

NO (If NO, complete (a))

I don't know

(a) Provide last known address of the person from whom you are divorced/dissolved or annulled. (Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)

Street

City

Enter your Social Security Number before going to the next page
Page 40

State

Zip Code

Country

I don't know

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 17 - Marital/Relationship Status - (Continued)
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?

YES

NO

17.2 Complete the following if you selected "divorced/dissolved", "annulled", or "widowed". Provide information about any person from whom you are
divorced/dissolved, annulled, or widowed.
Entry #2
Provide the full name.
Last name

Middle name

First name

Provide the place of birth.
City

State

Provide the country(ies) of citizenship.
Country #1

Zip Code

Provide the date of birth.
(Month/Day/Year)

Suffix

Est.

Country (Required)

Country #2

Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)
Est.
Provide the location. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
Country
City
State
Provide the status.
Divorced/Dissolved

Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)
Widowed

Annulled

Est.

Provide where the record of divorce/dissolution or annulment is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code
Is this person deceased?
YES

NO (If NO, complete (a))

I don't know

(a) Provide last known address of the person from whom you are divorced/dissolved or annulled. (Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)

Street

City

Enter your Social Security Number before going to the next page
Page 41

State

Zip Code

Country

I don't know

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 17 - Marital/Relationship Status - (Continued)
17.3

Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic
partner, with whom you share 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.

YES

NO (If NO, proceed to Section 18)

Complete the following if you presently reside with a cohabitant.
Entry #1
Provide the cohabitant full name.
Last name

First name

Middle name

Provide the cohabitant place of birth.
City

Provide the cohabitant date of birth.
Date (Month/Day/Year)
Est.

Suffix

Country (Required)

State

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.
FS 240 or 545

U.S. Passport (current or most recent)

DS 1350

Alien Registration

None (Provide explanation)

Other (Provide explanation)
U.S. Certificate of
Citizenship

U.S. Certificate of Naturalization

Provide document number.

Provide your cohabitant's U.S. Social Security Number.
Not applicable

Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each
name was used).
#1 Last name
Maiden name?

First name
From (Month/Year)

To (Month/Year)
Est.

#2 Last name
Maiden name?

To (Month/Year)
Est.

#3 Last name
Maiden name?

Est.

Maiden name?

Middle name

Suffix

Middle name

Suffix

Present
Est.

To (Month/Year)

Est.
Provide your cohabitant's country(ies) of citizenship.
Country #1

Suffix

Present

First name
From (Month/Year)

Middle name

Est.

To (Month/Year)

#4 Last name

Suffix

Present

First name
From (Month/Year)

Middle name

Est.
First name

From (Month/Year)

Not applicable

Present
Est.
Provide date cohabitation began.

Country #2

(Month/Day/Year)

Est.

Enter your Social Security Number before going to the next page
Page 42

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 17 - Marital/Relationship Status - (Continued)
17.3

Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic
partner, with whom you share 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.

YES

NO (If NO, proceed to Section 18)

Complete the following if you presently reside with a cohabitant.
Entry #2
Provide the cohabitant full name.
Last name

First name

Middle name

Provide the cohabitant place of birth.
City

Provide the cohabitant date of birth.
Date (Month/Day/Year)
Est.

Suffix

Country (Required)

State

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.
FS 240 or 545

U.S. Passport (current or most recent)

DS 1350

Alien Registration

None (Provide explanation)

Other (Provide explanation)
U.S. Certificate of
Citizenship

U.S. Certificate of Naturalization

Provide document number.

Provide your cohabitant's U.S. Social Security Number.
Not applicable

Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each
name was used).
#1 Last name
Maiden name?

First name
From (Month/Year)

To (Month/Year)
Est.

#2 Last name
Maiden name?

Est.

Maiden name?

To (Month/Year)
Est.

#4 Last name
Maiden name?

Middle name

Suffix

Middle name

Suffix

Present
Est.

To (Month/Year)

Est.
Provide your cohabitant's country(ies) of citizenship.
Country #1

Suffix

Present

First name
From (Month/Year)

Middle name

Est.
First name

From (Month/Year)

Suffix

Est.

To (Month/Year)

#3 Last name

Middle name
Present

First name
From (Month/Year)

Not applicable

Present
Est.
Provide date cohabitation began.

Country #2

(Month/Day/Year)

Est.

Enter your Social Security Number before going to the next page
Page 43

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

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.)
Select all that apply.
Mother
Foster parent
Sister
Half-sister
Father

Child (including adopted/foster)

Stepbrother

Father-in-law

Stepmother

Stepchild

Stepsister

Mother-in-law

Stepfather

Brother

Half-brother

Guardian

Entry #1
Provide relative type.
Provide your relative's full name.
Last name
Provide your relative's date of birth.
Date (Month/Year)

Middle name

First name
Provide your relative's place of birth.
City

Suffix

Country (Required)

State

Est.
Provide your relative's country(ies) of citizenship.
Country #2

Country #1

Entry #1

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
If mother, provide your mother's maiden name.

Same as listed

I don't know

First name

Last name

Middle name

Suffix

Has this relative used any other names?
YES

NO

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
#1 Last name

First name

Maiden name?
YES

From (Month/Year)

NO

To (Month/Year)
Est.

#2 Last name
From (Month/Year)

NO

To (Month/Year)
Est.

#3 Last name
From (Month/Year)

NO

NO

Est.

From (Month/Year)

Present

Suffix

Provide the reason(s) why the name changed.

Est.

To (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 44

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.

To (Month/Year)

#4 Last name

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.
First name

Maiden name?
YES

Middle name

Not applicable

Middle name
Present
Est.

Suffix

Provide the reason(s) why the name changed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
Is your relative deceased?

NO (If NO, proceed to 18.2)

YES

Entry #1

18.2 Complete the following if the relative listed is your 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 and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Does this relative have an APO/FPO address?
Provide your relative's APO/FPO address.
YES
Address
NO
I don't know

Enter your Social Security Number before going to the next page
Page 45

APO or FPO

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
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.)
Select all that apply.
Mother
Foster parent
Sister
Half-sister
Father

Child (including adopted/foster)

Stepbrother

Father-in-law

Stepmother

Stepchild

Stepsister

Mother-in-law

Stepfather

Brother

Half-brother

Guardian

Entry #2
Provide relative type.
Provide your relative's full name.
Last name
Provide your relative's date of birth.
Date (Month/Year)

Middle name

First name
Provide your relative's place of birth.
City

Suffix

Country (Required)

State

Est.
Provide your relative's country(ies) of citizenship.
Country #2

Country #1

Entry #2

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
If mother, provide your mother's maiden name.

Same as listed

I don't know

First name

Last name

Middle name

Suffix

Has this relative used any other names?
YES

NO

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
#1 Last name

First name

Maiden name?
YES

From (Month/Year)

NO

To (Month/Year)
Est.

#2 Last name
From (Month/Year)

NO

Est.

From (Month/Year)

NO

NO

Est.

From (Month/Year)

Present

Suffix

Provide the reason(s) why the name changed.

Est.

To (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 46

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.

To (Month/Year)

#4 Last name

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?

Suffix

Est.

To (Month/Year)

#3 Last name

YES

Present

First name

Maiden name?
YES

Middle name

Not applicable

Middle name
Present
Est.

Suffix

Provide the reason(s) why the name changed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #2

18.2 Complete the following if the relative listed is your 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 and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Does this relative have an APO/FPO address?
Provide your relative's APO/FPO address.
YES
Address
NO
I don't know

Enter your Social Security Number before going to the next page
Page 47

APO or FPO

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
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.)
Select all that apply.
Mother
Foster parent
Sister
Half-sister
Father

Child (including adopted/foster)

Stepbrother

Father-in-law

Stepmother

Stepchild

Stepsister

Mother-in-law

Stepfather

Brother

Half-brother

Guardian

Entry #3
Provide relative type.
Provide your relative's full name.
Last name
Provide your relative's date of birth.
Date (Month/Year)

Middle name

First name
Provide your relative's place of birth.
City

Suffix

Country (Required)

State

Est.
Provide your relative's country(ies) of citizenship.
Country #2

Country #1

Entry #3

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
If mother, provide your mother's maiden name.

Same as listed

I don't know

First name

Last name

Middle name

Suffix

Has this relative used any other names?
YES

NO

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
#1 Last name

First name

Maiden name?
YES

From (Month/Year)

NO

To (Month/Year)
Est.

#2 Last name
From (Month/Year)

NO

To (Month/Year)
Est.

#3 Last name
From (Month/Year)

NO

NO

Est.

From (Month/Year)

Present

Suffix

Provide the reason(s) why the name changed.

Est.

To (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 48

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.

To (Month/Year)

#4 Last name

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.
First name

Maiden name?
YES

Middle name

Not applicable

Middle name
Present
Est.

Suffix

Provide the reason(s) why the name changed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #3

18.2 Complete the following if the relative listed is your 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 and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Does this relative have an APO/FPO address?
Provide your relative's APO/FPO address.
YES
Address
NO
I don't know

Enter your Social Security Number before going to the next page
Page 49

APO or FPO

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
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.)
Select all that apply.
Mother
Foster parent
Sister
Half-sister
Father

Child (including adopted/foster)

Stepbrother

Father-in-law

Stepmother

Stepchild

Stepsister

Mother-in-law

Stepfather

Brother

Half-brother

Guardian

Entry #4
Provide relative type.
Provide your relative's full name.
Last name
Provide your relative's date of birth.
Date (Month/Year)

Middle name

First name
Provide your relative's place of birth.
City

Suffix

Country (Required)

State

Est.
Provide your relative's country(ies) of citizenship.
Country #2

Country #1

Entry #4

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
Same as listed

If mother, provide your mother's maiden name.

I don't know

First name

Last name

Middle name

Suffix

Has this relative used any other names?
YES

NO

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
First name

#1 Last name
Maiden name?
YES

From (Month/Year)

NO

To (Month/Year)
Est.

Maiden name?

From (Month/Year)

NO

To (Month/Year)
Est.

Maiden name?

From (Month/Year)

NO

NO

Est.

From (Month/Year)

Present

Suffix

Provide the reason(s) why the name changed.

Est.

To (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 50

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.

To (Month/Year)

#4 Last name

Provide the reason(s) why the name changed.
Middle name

First name

#3 Last name

YES

Present

Suffix

Est.
First name

#2 Last name

YES

Middle name

Not applicable

Middle name
Present
Est.

Suffix

Provide the reason(s) why the name changed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #4

18.2 Complete the following if the relative listed is your 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 and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Does this relative have an APO/FPO address?
Provide your relative's APO/FPO address.
YES
Address
NO
I don't know

Enter your Social Security Number before going to the next page
Page 51

APO or FPO

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
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.)
Select all that apply.
Mother
Foster parent
Sister
Half-sister
Father

Child (including adopted/foster)

Stepbrother

Father-in-law

Stepmother

Stepchild

Stepsister

Mother-in-law

Stepfather

Brother

Half-brother

Guardian

Entry #5
Provide relative type.
Provide your relative's full name.
Last name
Provide your relative's date of birth.
Date (Month/Year)

Middle name

First name
Provide your relative's place of birth.
City

Suffix

Country (Required)

State

Est.
Provide your relative's country(ies) of citizenship.
Country #2

Country #1

Entry #5

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
If mother, provide your mother's maiden name.

Same as listed

I don't know

First name

Last name

Middle name

Suffix

Has this relative used any other names?
YES

NO

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
#1 Last name

First name

Maiden name?
YES

From (Month/Year)

NO

To (Month/Year)
Est.

#2 Last name
From (Month/Year)

NO

Est.

From (Month/Year)

NO

NO

Est.

From (Month/Year)

Present

Suffix

Provide the reason(s) why the name changed.

Est.

To (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 52

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.

To (Month/Year)

#4 Last name

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?

Suffix

Est.

To (Month/Year)

#3 Last name

YES

Present

First name

Maiden name?
YES

Middle name

Not applicable

Middle name
Present
Est.

Suffix

Provide the reason(s) why the name changed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #5

18.2 Complete the following if the relative listed is your 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 and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Does this relative have an APO/FPO address?
Provide your relative's APO/FPO address.
YES
Address
NO
I don't know

Enter your Social Security Number before going to the next page
Page 53

APO or FPO

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
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.)
Select all that apply.
Mother
Foster parent
Sister
Half-sister
Father

Child (including adopted/foster)

Stepbrother

Father-in-law

Stepmother

Stepchild

Stepsister

Mother-in-law

Stepfather

Brother

Half-brother

Guardian

Entry #6
Provide relative type.
Provide your relative's full name.
Last name
Provide your relative's date of birth.
Date (Month/Year)

Middle name

First name
Provide your relative's place of birth.
City

Suffix

Country (Required)

State

Est.
Provide your relative's country(ies) of citizenship.
Country #2

Country #1

Entry #6

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
If mother, provide your mother's maiden name.

Same as listed

I don't know

First name

Last name

Middle name

Suffix

Has this relative used any other names?
YES

NO

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
#1 Last name

First name

Maiden name?
YES

From (Month/Year)

NO

To (Month/Year)
Est.

#2 Last name
From (Month/Year)

NO

Est.

From (Month/Year)

NO

NO

Est.

From (Month/Year)

Present

Suffix

Provide the reason(s) why the name changed.

Est.

To (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 54

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?
YES

Present

Suffix

Est.

To (Month/Year)

#4 Last name

Provide the reason(s) why the name changed.
Middle name

First name

Maiden name?

Suffix

Est.

To (Month/Year)

#3 Last name

YES

Present

First name

Maiden name?
YES

Middle name

Not applicable

Middle name
Present
Est.

Suffix

Provide the reason(s) why the name changed.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 18 - Relatives - (Continued)
Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #6

18.2 Complete the following if the relative listed is your 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 and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Does this relative have an APO/FPO address?
Provide your relative's APO/FPO address.
YES
Address
NO
I don't know

Enter your Social Security Number before going to the next page
Page 55

APO or FPO

APO/FPO State Code

Zip Code

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 19 - Foreign Countries You have Visited
Have you traveled outside the U.S. in the last seven (7) years?

YES

Has your travel in the last seven (7) years been solely for U.S. Government business/military overseas
assignment on official government orders (i.e., no personal trips in conjunction with the official U.S.
Government business)?

NO (If NO, proceed to Section 20)

YES (If YES, proceed to Section 20)

NO

Complete the following if you responded 'Yes' to having 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.
Entry #1
Provide the country visited.

Provide the dates of your travel to this country.
From (Month/Year)
To (Month/Year)
Est.

Provide the total number of days involved in the visit.
Present

1-5

11-20

More than 30

Est.

6-10

21-30

Many short trips

Provide the purpose of the travel to this country (Select all that apply).
Business/Professional

Education

Trade shows, conferences, and seminars

Volunteer activities

Tourism

Visit family or friends

Other

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
YES
If yes, provide explanation.
NO
While traveling to or in this country, were you involved in any encounter with the police?
YES

If yes, provide explanation.

NO
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
YES

If yes, provide explanation.

NO
Complete the following if you responded 'Yes' to having 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.
Entry #2
Provide the country visited.

Provide the dates of your travel to this country.
From (Month/Year)
To (Month/Year)
Est.

Provide the total number of days involved in the visit.
Present

1-5

11-20

More than 30

Est.

6-10

21-30

Many short trips

Provide the purpose of the travel to this country (Select all that apply).
Business/Professional

Education

Trade shows, conferences, and seminars

Volunteer activities

Tourism

Visit family or friends

Other

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
YES
If yes, provide explanation.
NO
While traveling to or in this country, were you involved in any encounter with the police?
YES

If yes, provide explanation.

NO
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
YES

If yes, provide explanation.

NO

Enter your Social Security Number before going to the next page
Page 56

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 19 - Foreign Countries You have Visited - Continued
Complete the following if you responded 'Yes' to having 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.
Entry #3
Provide the country visited.

Provide the dates of your travel to this country.
From (Month/Year)
To (Month/Year)
Est.

Provide the total number of days involved in the visit.
Present

1-5

11-20

More than 30

Est.

6-10

21-30

Many short trips

Provide the purpose of the travel to this country (Select all that apply).
Business/Professional

Education

Trade shows, conferences, and seminars

Volunteer activities

Tourism

Visit family or friends

Other

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
YES
If yes, provide explanation.
NO
While traveling to or in this country, were you involved in any encounter with the police?
YES

If yes, provide explanation.

NO
While traveling to or in this country, were you involved in any encounter with the police?
YES

If yes, provide explanation.

NO
Complete the following if you responded 'Yes' to having 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.
Entry #4
Provide the country visited.

Provide the dates of your travel to this country.
To (Month/Year)
From (Month/Year)
Est.

Provide the total number of days involved in the visit.
Present

1-5

11-20

More than 30

Est.

6-10

21-30

Many short trips

Provide the purpose of the travel to this country (Select all that apply).
Business/Professional

Education

Trade shows, conferences, and seminars

Volunteer activities

Tourism

Visit family or friends

Other

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
YES
If yes, provide explanation.
NO
While traveling to or in this country, were you involved in any encounter with the police?
YES

If yes, provide explanation.

NO
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
YES

If yes, provide explanation.

NO

Enter your Social Security Number before going to the next page
Page 57

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record
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.
20.1

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.)

YES

NO (If NO, proceed to 20.2)

Entry #1

- 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?
Entry #1
Provide a description of the specific nature of the offense.

Provide the date of offense. (Month/Year)
Est.
(a) Did this offense involve any of the following?
YES

NO

(Select 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?
Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
City
County
State
Zip Code
(b) Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other
type of law enforcement official?
YES

NO (If NO, proceed to (c))

Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
State
City
County
Zip Code
(c) As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?
YES

Provide the name of the court.

NO

Provide explanation

(If YES, complete (c.1))

(c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
City
County
State
Zip Code
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge
dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser
offense.
Felony/misdemeanor

Charge

Outcome

Date (Month/Year)
Est.
Est.
Est.
Est.

Enter your Social Security Number before going to the next page
Page 58

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record - (Continued)
Entry #1
(d) Were you sentenced as a result of this offense?
YES (If YES, complete (d.1))

NO (If NO, complete (d.2))

(d.1)

Entry #1

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year?

YES

NO

Were you incarcerated as a result of that sentence for not less than 1 year?

YES

NO

If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.

Not Applicable From Date (Month/Year)

If conviction resulted in probation or parole, provide the dates of
probation or parole.

Not Applicable From Date (Month/Year)

To Date (Month/Year)

Present
Est.

Est.
To Date (Month/Year)

Present
Est.

Est.

(d.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
Provide explanation.

Enter your Social Security Number before going to the next page
Page 59

YES

NO

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record - (Continued)

Entry #2

Complete the following if you have responded 'Yes' to one of the following;
- 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?
Entry #2
Provide the date of offense. (Month/Year)

Provide a description of the specific nature of the offense.
Est.

(a) Did this offense involve any of the following?
YES

NO

(Select 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?
Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
City
County
State
Zip Code
(b) Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other
type of law enforcement official?
YES

NO (If NO, proceed to (c))

Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
State
City
County
Zip Code
(c) As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?
YES

Provide the name of the court.

NO

Provide explanation

(If YES, complete (c.1))

(c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
City
County
State
Zip Code
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge
dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser
offense.
Felony/misdemeanor

Charge

Outcome

Date (Month/Year)
Est.
Est.
Est.
Est.

Enter your Social Security Number before going to the next page
Page 60

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record - (Continued)
Entry #2
(d) Were you sentenced as a result of this offense?
YES (If YES, complete (d.1))

NO (If NO, complete (d.2))

(d.1)

Entry #2

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year?

YES

NO

Were you incarcerated as a result of that sentence for not less than 1 year?

YES

NO

If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.

Not Applicable From Date (Month/Year)

If conviction resulted in probation or parole, provide the dates of
probation or parole.

Not Applicable From Date (Month/Year)

To Date (Month/Year)

Present
Est.

Est.
To Date (Month/Year)

Present
Est.

Est.

(d.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
Provide explanation.

Enter your Social Security Number before going to the next page
Page 61

YES

NO

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record - (Continued)
Other than those offenses already listed, have you EVER had the following happen to you?

20.2

YES

NO (If NO, proceed to 20.3)

- 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?
Entry #1
Provide the date of offense. (Month/Year)

Provide a description of the specific nature of the offense.
Est.

(a) Did this offense involve any of the following?
YES

NO

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?
Provide the name of the court.
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
State
City
County
Zip Code
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

Charge

Outcome

Date (Month/Year)
Est.
Est.
Est.
Est.

(b) Were you sentenced as a result of these charges?
YES (If YES, complete (b.1))

NO (If NO, complete (b.2))

(b.1)
Provide a description of the sentence.
Were you sentenced to imprisonment for a term exceeding 1 year?

YES

NO

Were you incarcerated as a result of that sentence for not less than 1 year?

YES

NO

If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.

Not Applicable From Date (Month/Year)

If conviction resulted in probation or parole, provide the dates of
probation or parole.

Not Applicable From Date (Month/Year)

Est.

(b.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES

NO

Provide explanation.

Enter your Social Security Number before going to the next page
Page 62

To Date (Month/Year)

Est.

Present
Est.

To Date (Month/Year)

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record - (Continued)
Entry #2
Provide the date of offense. (Month/Year)

Provide a description of the specific nature of the offense.
Est.

(a) Did this offense involve any of the following?
YES

NO

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?
Provide the name of the court.
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Country
State
City
County
Zip Code
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

Charge

Outcome

Date (Month/Year)
Est.
Est.
Est.
Est.

(b) Were you sentenced as a result of these charges?
YES (If YES, complete (b.1))

NO (If NO, complete (b.2))

(b.1)
Provide a description of the sentence.
Did this offense involve any of the following?

YES

NO

Were you incarcerated as a result of that sentence for not less than 1 year?

YES

NO

If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.
If conviction resulted in probation or parole, provide the dates of
probation or parole.

Not Applicable

From Date (Month/Year)

Not Applicable

From Date (Month/Year)

Est.

(b.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES

NO

Provide explanation.

Enter your Social Security Number before going to the next page
Page 63

To Date (Month/Year)

Est.

Present
Est.

To Date (Month/Year)

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 20 - Police Record - (Continued)
20.3

Is there currently a domestic violence protective order or restraining order issued against you?

YES

NO (If NO, proceed to Section 21)

Complete the following if you responded 'Yes' to currently having a domestic violence protective order or restraining order issued against you?
Entry #1
Provide explanation.
Provide the date the order was issued. (Month/Year)

Provide the name of the court or agency that issued the order.
Est.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code
Entry #2
Provide explanation.
Provide the date the order was issued. (Month/Year)

Provide the name of the court or agency that issued the order.
Est.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code
Entry #3
Provide explanation.
Provide the date the order was issued. (Month/Year)

Provide the name of the court or agency that issued the order.
Est.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code
Entry #4
Provide explanation.
Provide the date the order was issued. (Month/Year)

Provide the name of the court or agency that issued the order.
Est.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Country
City
State
Zip Code

Enter your Social Security Number before going to the next page
Page 64

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity
You are required to answer the questions. 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 not 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 includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise
consuming any drug or controlled substance.

21.1

YES

NO (If NO, proceed to 21.2)

Complete the following if you answered 'Yes' to in the last seven (7) years having illegally used a drug or controlled substance.
Entry #1
Provide the type of drug or controlled substance.
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.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide an estimate of the month and
year of most recent use. (Month/Year)

Provide an estimate of the month
and year of first use. (Month/Year)
Est.

Provide nature of use, frequency, and number of times used.
Est.

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in
a position directly and immediately affecting the public safety?

YES

NO

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.

Entry #2
Provide the type of drug or controlled substance.
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.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide an estimate of the month and
year of most recent use. (Month/Year)

Provide an estimate of the month
and year of first use. (Month/Year)
Est.

Provide nature of use, frequency, and number of times used.
Est.

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in
a position directly and immediately affecting the public safety?

YES

NO

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.

Enter your Social Security Number before going to the next page
Page 65

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
21.2

In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation,
trafficking, production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?

YES

NO (If NO, proceed to 21.3)

Complete the following if 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.
Entry #1
Provide the type of drug or controlled substance.
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.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide an estimate of the month and
year of first involvement. (Month/Year)

Provide the nature and frequency of activity.

Provide an estimate of the month and year
of most recent involvement. (Month/Year)
Est.

Est.

Provide the reason(s) why you engaged in the activity.
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a
position directly and immediately affecting the public safety?

YES

NO

Was your involvement while possessing a security clearance?

YES

NO

Do you intend to engage in this activity in the future?
YES

Provide explanation.

NO
Entry #2
Provide the type of drug or controlled substance.
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.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)
Provide an estimate of the month and year
of most recent involvement. (Month/Year)

Provide an estimate of the month and
year of first involvement. (Month/Year)
Est.

Provide the nature and frequency of activity.
Est.

Provide the reason(s) why you engaged in the activity.
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a
position directly and immediately affecting the public safety?

YES

NO

Was your involvement while possessing a security clearance?

YES

NO

Do you intend to engage in this activity in the future?
YES

Provide explanation.

NO

Enter your Social Security Number before going to the next page
Page 66

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
21.3

In the last seven (7) years, have you 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 the public safety other than previously listed?

YES

NO (If NO, proceed to 21.4)

Complete the following if you responded 'Yes' to having in the last seven (7) years, 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 the public
safety other than previously listed.
Entry #1
Provide a description of the drugs or controlled substances used and your involvement.
Provide the dates of involvement/use.
From Date

(Month/Year)

To Date (Month/Year)

Est.

Present

Provide an estimate of the number of times you used and/or were involved with this
drug or controlled substance while employed in this capacity.

Est.

Entry #2
Provide a description of the drugs or controlled substances used and your involvement.
Provide the dates of involvement/use.
From Date (Month/Year)
To Date (Month/Year)
Est.

Present

Provide an estimate of the number of times you used and/or were involved with this
drug or controlled substance while employed in this capacity.

Est.

Enter your Social Security Number before going to the next page
Page 67

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
21.4

In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of
whether or not the drugs were prescribed for you or someone else?

YES

NO (If NO, proceed to 21.5)

Complete the following if you responded 'Yes' to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless
of whether the drugs were prescribed for you or someone else.
Entry #1
Provide the name of the prescription drug that you misused.
Provide the dates of involvement in the above.
From Date (Month/Year)
To Date (Month/Year)
Est.

Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Present
Est.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a
position directly and immediately affecting the public safety?

YES

NO

Was your involvement while possessing a security clearance?

YES

NO

Entry #2
Provide the name of the prescription drug that you misused.
Provide the dates of involvement in the above.
From Date (Month/Year)
To Date (Month/Year)
Est.

Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Present
Est.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a
position directly and immediately affecting the public safety?

YES

NO

Was your involvement while possessing a security clearance?

YES

NO

Enter your Social Security Number before going to the next page
Page 68

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
21.5

In the last seven (7) years have you been ordered, advised, or asked to seek counseling or
treatment as a result of your illegal use of drugs or controlled substances?

YES

NO (If NO, proceed to 21.6)

Complete the following if you responded 'Yes' to In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a
result of your illegal use of drugs or controlled substances.
Entry #1
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 controlled substances?
(Select all that apply):
An employer, military commander, or employee assistance program

A court official / judge

A medical professional

I have not been ordered, advised, or asked to seek
counseling or treatment by any of the above.

A mental health professional
Provide explanation

YES (If YES, complete (b))

Did you take action to receive counseling or treatment?

NO (If NO, complete (a))

(a) You have indicated that you did not receive treatment.
Provide explanation.
(b) You have indicated that you did receive treatment.
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.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide the name of the treatment provider.
Last name

First name

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a telephone number for the
treatment provider.

Did you successfully complete the treatment?

Extension

YES

International or DSN
phone number
Day

Night

NO

(Provide explanation)

Enter your Social Security Number before going to the next page
Page 69

Provide the dates of treatment.
From Date (Month/Year) To Date (Month/Year)
Est.

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
Complete the following if you responded 'Yes' to In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a
result of your illegal use of drugs or controlled substances.
Entry #2
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 controlled substances?
(Select all that apply):
An employer, military commander, or employee assistance program
A court official / judge
A medical professional

I have not been ordered, advised, or asked to seek
counseling or treatment by any of the above.

A mental health professional
Provide explanation

YES (If YES, complete (b))

Did you take action to receive counseling or treatment?

NO (If NO, complete (a))

(a) You have indicated that you did not receive treatment.
Provide explanation.
(b) You have indicated that you did receive treatment.
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.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide the name of the treatment provider.
Last name

First name

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a telephone number for the
treatment provider.

Did you successfully complete the treatment?

Extension

YES

International or DSN
phone number
Day

Night

NO

(Provide explanation)

Enter your Social Security Number before going to the next page
Page 70

Provide the dates of treatment.
From Date (Month/Year) To Date (Month/Year)
Est.

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
21.6

In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your
use of a drug or controlled substance?

YES

NO (If NO, proceed to Section 22)

Complete the following if you responded 'Yes' to In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of a
drug or controlled substance.
Entry #1
Provide the type of drug or controlled substance for which you were treated.
Cocaine or crack cocaine (Such as rock, freebase, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Ketamine (Such as special K, jet, etc.)

Steroids (Such as the clear, juice, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Other (Provide explanation)

Provide the name of the treatment provider.
Last name

First name

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a telephone number for the
treatment provider.

Did you successfully complete the treatment?

Extension

YES

International or DSN phone
number

Provide the dates of treatment.
From Date (Month/Year)
To Date (Month/Year)

Day

Night

NO

(Provide explanation)

Est.

Present
Est.

Entry #2
Provide the type of drug or controlled substance for which you were treated.
Cocaine or crack cocaine (Such as rock, freebase, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Ketamine (Such as special K, jet, etc.)

Steroids (Such as the clear, juice, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Other (Provide explanation)

Provide the name of the treatment provider.
Last name

First name

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a telephone number for the
treatment provider.

Did you successfully complete the treatment?

Extension

YES

International or DSN phone
number
Day
Night
NO

(Provide explanation)

Enter your Social Security Number before going to the next page
Page 71

Provide the dates of treatment.
From Date (Month/Year)
To Date (Month/Year)
Est.

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 22 - Use of Alcohol
22.1

In the last seven (7) years has your use of alcohol 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?

YES

NO (If NO, proceed to 22.2)

Complete the following if 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.
Entry #1
Provide the month/year when this negative impact occurred.
From Date (Month/Year)

Provide dates of involvement or use.
From Date (Month/Year)
To Date (Month/Year)

Est.

Est.

Present
Est.

Provide an explanation of the circumstances and the negative impact.
Provide circumstances.

Provide negative impact.

Entry #2
Provide the month/year when this negative impact occurred.
From Date (Month/Year)

Provide dates of involvement or use.
From Date (Month/Year)
To Date (Month/Year)

Est.
Provide an explanation of the circumstances and the negative impact.
Provide circumstances.

Est.

Present
Est.

Provide negative impact.

Entry #3
Provide the month/year when this negative impact occurred.
From Date (Month/Year)

Provide dates of involvement or use.
From Date (Month/Year)
To Date (Month/Year)

Est.
Provide an explanation of the circumstances and the negative impact.
Provide circumstances.

Est.

Present
Est.

Provide negative impact.

Entry #4
Provide the month/year when this negative impact occurred.
From Date (Month/Year)
Est.
Provide an explanation of the circumstances and the negative impact.
Provide circumstances.

Enter your Social Security Number before going to the next page
Page 72

Provide dates of involvement or use.
From Date (Month/Year)
To Date (Month/Year)
Est.
Provide negative impact.

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 22 - Use of Alcohol - (Continued)
22.2

In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a
result of your use of alcohol?

YES

NO (If NO, proceed to 22.3)

Complete the following if you responded 'Yes' to having been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol.
Entry #1
YES (If YES, complete (b))

Did you take action to receive counseling or treatment?
(a)

NO (If NO, complete (a))

You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.
Provide explanation.

(b) You responded 'Yes' to having taken action to seek counseling or treatment.
Provide the dates of counseling or treatment.
From Date (Month/Year)
To Date (Month/Year)
Est.

Provide the name of the individual counselor or treatment provider.
Present
Est.

Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Did you successfully complete the treatment program?

YES

NO

Night
(Provide explanation)

Entry #2
YES (If YES, complete (b))

Did you take action to receive counseling or treatment?
(a)

NO (If NO, complete (a))

You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.
Provide explanation.

(b) You responded 'Yes' to having taken action to seek counseling or treatment.
Provide the dates of counseling or treatment.
From Date (Month/Year)
To Date (Month/Year)
Est.

Provide the name of the individual counselor or treatment provider.
Present
Est.

Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Did you successfully complete the treatment program?

YES

Enter your Social Security Number before going to the next page
Page 73

NO

Night
(Provide explanation)

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 22 - Use of Alcohol - (Continued)
22.3 In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of alcohol?

YES

NO (If NO, proceed to 23)

Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment.
Entry #1
Provide the dates of counseling or treatment.
From Date (Month/Year)
To Date (Month/Year)
Est.

Provide the name of the individual counselor or treatment provider.
Present
Est.

Provide the full address of the counseling or treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Did you successfully complete the treatment program?

YES

Entry #2
Provide the dates of counseling or treatment.
From Date (Month/Year)
To Date (Month/Year)

Present

Est.

NO

Night
(Provide explanation)

Provide the name of the individual counselor or treatment provider.
Est.

Provide the full address of the counseling or treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide telephone number.

Extension

International or DSN phone number
Day

Did you successfully complete the treatment program?

YES

Enter your Social Security Number before going to the next page
Page 74

NO

Night
(Provide explanation)

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 23 - Investigations and Clearance Record
23.1

Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you
a security clearance eligibility/access?

YES

NO (If NO, proceed to 23.2)

Complete the following if 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.
Entry #1
Provide the investigating agency:
U.S. Department of Defense

U.S. Department of Homeland Security

U.S. Department of State

Foreign government (Provide name of government)

U.S. Office of Personnel Management

I don't know

Federal Bureau of Investigation

Other (Provide explanation)

U.S. Department of Treasury (Provide name of bureau)
Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

Date the investigation was completed (Month/Year)

I don't know

Provide the date clearance eligibility/access was granted. (Month/Year)

Est.

I don't know
Est.

Provide the level of clearance eligibility/access granted:
None

Q

Confidential

L

Secret

I don't know

Top Secret

Issued by foreign country

Sensitive Compartmented Information (SCI)

Other (Provide explanation)

Entry #2
Provide the investigating agency:
U.S. Department of Defense

U.S. Department of Homeland Security

U.S. Department of State

Foreign government (Provide name of government)

U.S. Office of Personnel Management

I don't know

Federal Bureau of Investigation

Other (Provide explanation)

U.S. Department of Treasury (Provide name of bureau)
Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

Date the investigation was completed (Month/Year)

I don't know Provide the date clearance eligibility/access was granted. (Month/Year)

I don't know

Est.

Est.

Provide the level of clearance eligibility/access granted:
None

Q

Confidential

L

Secret

I don't know

Top Secret

Issued by foreign country

Sensitive Compartmented Information (SCI)

Other (Provide explanation)

Enter your Social Security Number before going to the next page
Page 75

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 23 - Investigations and Clearance Record - (Continued)
23.2

Have you EVER had a security clearance eligibility/access authorization denied, suspended, or
revoked? (Note: An administrative downgrade or administrative termination of a security clearance is
not a revocation.)

YES

NO (If NO, proceed to 23.3)

Complete the following if you responded 'Yes' to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.
Entry #1
Provide the date security clearance
eligibility/access authorization was denied,
suspended or revoked. (Month/Year)

Provide the name of the agency that took
the action.

Provide an explanation of the circumstances of the
denial,suspension or revocation action.

Provide the name of the agency that took
the action.

Provide an explanation of the circumstances of the
denial,suspension or revocation action.

Est.
Entry #2
Provide the date security clearance
eligibility/access authorization was denied,
suspended or revoked. (Month/Year)
Est.
23.3

Have you EVER been debarred from government employment?

YES

NO (If NO, proceed to Section 24)

Complete the following if you responded 'Yes' to having EVER been debarred from government employment.
Entry #1
Provide the name of the government
agency taking debarment action.

Provide an explanation of the circumstances of the
debarment.

Provide the date the debarment occurred.
(Month/Year)

Est.
Entry #2
Provide the name of the government
agency taking debarment action.

Provide an explanation of the circumstances of the
debarment.

Provide the date the debarment occurred.
(Month/Year)

Est.

Enter your Social Security Number before going to the next page
Page 76

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?

24.1

YES

NO (If NO, proceed to 24.2)

Complete the following if you responded 'Yes' to in the last seven (7) years having filed a petition under any chapter of the bankruptcy code.
Entry #1
Select the applicable bankruptcy petition type.
Chapter 7

Chapter 11

Provide the bankruptcy court docket/account number.

Chapter 12

Provide the date bankruptcy was
filed. (Month/Year)

Chapter 13

Provide the date of bankruptcy
discharge. (Month/Year)

Not Applicable

Est.

Est.

Est.
Provide the name debt is recorded under.
Last name

Provide the total amount (in U.S.
dollars) involved in the bankruptcy.

First name

Suffix

Middle name

Provide the name of the court involved.
Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
(a) If Chapter 13 or Chapter 12 previously selected:
Provide the name of the trustee for this bankruptcy.

Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City

Street

State

Country

Zip Code

Were you discharged of all debts claimed in the bankruptcy?

YES (Provide explanation)

NO (Provide explanation)

Provide Explanation.
Entry #2
Select the applicable bankruptcy petition type.
Chapter 7

Chapter 11

Provide the bankruptcy court docket/account number.

Chapter 12

Provide the date bankruptcy was
filed. (Month/Year)

Chapter 13

Provide the date of bankruptcy
discharge. (Month/Year)

Not Applicable

Est.

Est.

Est.
Provide the name debt is recorded under.
Last name

Provide the total amount (in U.S.
dollars) involved in the bankruptcy.

First name

Suffix

Middle name

Provide the name of the court involved.
Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
(a) If Chapter 13 or Chapter 12 previously selected:
Provide the name of the trustee for this bankruptcy.

Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street

City

Were you discharged of all debts claimed in the bankruptcy?
Provide Explanation.

Enter your Social Security Number before going to the next page
Page 77

State

Zip Code

Country

YES (Provide explanation)

NO (Provide explanation)

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record - (Continued)
24.2

In the last seven(7) years have you failed to meet financial obligations due to gambling?

YES

NO (If NO, proceed to 24.3)

Complete the following if you responded 'Yes' to having failed to meet financial obligations due to gambling.
Entry #1
Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.
From Date (Month/Year)

To Date (Month/Year)
Est.

Present
Est.

Provide a description of your financial problems due to gambling.

If you have taken any action(s) to rectify your financial problems due to gambling, provide
a description of your actions. If you have not taken any action(s), provide explanation.

Entry #2
Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.
From Date (Month/Year)

To Date (Month/Year)
Est.

Present
Est.

Provide a description of your financial problems due to gambling.

24.3

If you have taken any action(s) to rectify your financial problems due to gambling, provide
a description of your actions. If you have not taken any action(s), provide explanation.

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 (If NO, proceed to 24.4)

Complete the following if you responded 'Yes' to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Entry #1

Did you fail to file, pay as required, or both?
File

Pay

Provide the year you failed to file or pay your Federal, state, or other taxes.
Est.

Both

Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency
to which you failed to file or pay taxes.
Provide the amount (in U.S. dollars) of the taxes.

Provide date satisfied. (Month/Year)
Est.

Provide the type of taxes you failed to file or
pay (such as property, income, sales, etc.).

Not Applicable
Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s) provide explanation.

Entry #2

Did you fail to file, pay as required, or both?
File

Pay

Provide the year you failed to file or pay your Federal, state, or other taxes.
Est.

Both

Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency
to which you failed to file or pay taxes.
Provide the amount (in U.S. dollars) of the taxes.

Provide date satisfied. (Month/Year)
Est.

Provide the type of taxes you failed to file or
pay (such as property, income, sales, etc.).

Not Applicable
Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s) provide explanation.

Enter your Social Security Number before going to the next page
Page 78

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record - (Continued)
24.4

In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of
agreement for a travel or credit card provided by your employer?

YES

NO (If NO, proceed to 24.5)

Complete the following if 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.
Entry #1
Provide the name of the agency or company.
Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Provide the reason(s) for the counseling, warning, or disciplinary action.
Provide the amount (in U.S. dollars)
of violation.

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any
action(s) provide explanation.
Est.

Entry #2
Provide the name of the agency or company.
Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
State
Street
Zip Code
Provide the reason(s) for the counseling, warning, or disciplinary action.
Provide the amount (in U.S. dollars)
of violation.

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any
action(s) provide explanation.
Est.

24.5

Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to
resolve an inability to meet financial obligations?

YES

NO (If NO, proceed to 24.6)

Complete the following if you responded 'Yes' to currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve
an inability to meet financial obligations.
Entry #1
Provide explanation.

Provide the name of the credit counseling organization or resource.

Provide the telephone number of the credit counseling organization.
Telephone number
Extension
International or DSN phone number
Day

Provide the location of the credit counseling organization.
City
State

Night

As a result of this counseling, provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken
any action(s), provide explanation.

Entry #2
Provide the name of the credit counseling organization or resource.

Provide explanation.

Provide the telephone number of the credit counseling organization.
Telephone number
Extension
International or DSN phone number
Day

Provide the location of the credit counseling organization.
City
State

Night

As a result of this counseling, provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken
any action(s), provide explanation.

Enter your Social Security Number before going to the next page
Page 79

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record - (Continued)
24.6

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)
- You are currently 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 (If NO, proceed to 24.7)

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Entry #1
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to 24.7)

You are currently 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).
Provide the associated loan/account number(s) involved.

Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.
Provide the date the financial
issue began. (Month/Year)

Provide date the financial issue
was resolved. (Month/Year)
Est.

Provide the name of the court involved.
Not Resolved
Est.

Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page
Page 80

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record - (Continued)
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Entry #2
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to 24.7)

You are currently 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).
Provide the associated loan/account number(s) involved.

Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.
Provide the date the financial
issue began. (Month/Year)

Provide date the financial issue
was resolved. (Month/Year)
Est.

Provide the name of the court involved.
Not Resolved
Est.

Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page
Page 81

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record - (Continued)
24.7

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 wages, benefits, or assets garnished or attached
for any reason?
- In the last seven (7) years, you were 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 (If NO, proceed to Section 25)

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Entry #1
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to Section 25)

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 wages, benefits, or assets garnished or attached for any reason?
In the last seven (7) years, you were 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).
Provide the associated loan/account number(s) involved.

Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.
Provide the date the financial issue began. (Month/Year)

Provide date the financial issue was resolved. (Month/Year)
Est.

Not Resolved
Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page
Page 82

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 24 - Financial Record - (Continued)
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Entry #2
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to Section 25)

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 wages, benefits, or assets garnished or attached for any reason?
In the last seven (7) years, you were 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).
Provide the associated loan/account number(s) involved.

Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.
Provide the date the financial issue began. (Month/Year)

Provide date the financial issue was resolved. (Month/Year)
Est.

Not Resolved
Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page
Page 83

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 25 - Use of Information Technology Systems
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.
25.1

In the last seven (7) years have you illegally or without proper authorization accessed or attempted to
access any information technology system?

YES

NO (If NO, proceed to 25.2)

Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into
any information technology system.
Entry #1
Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Entry #2
Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

25.2

In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the
above?

YES

NO (If NO, proceed to 25.3)

Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the above.
Entry #1
Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Entry #2
Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Enter your Social Security Number before going to the next page
Page 84

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 25 - Use of Information Technology Systems - (Continued)
25.3

In the last seven (7) years have you introduced, removed, or used hardware, software, or media in
connection with any information technology system without authorization, when specifically prohibited
by rules, procedures, guidelines, or regulations or attempted any of the above?

YES

NO (If NO, proceed to Section 26)

Complete the following if you responded 'Yes' to having in the last seven (7) years introduced, removed, or used hardware, software, or media in
connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or
attempted any of the above.
Entry #1
Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Entry #2
Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Enter your Social Security Number before going to the next page
Page 85

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 26 - Involvement in Non-Criminal Court Actions
In the last seven (7) years, have you been a party to any public record civil court action not listed elsewhere on
this form?

YES

NO (If NO, proceed to Section 27)

Complete the following if 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
seven (7) years.
Entry #1
Provide the date of the civil action. (Month/Year)

Provide the court name.

Est.
Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide a description of the results of the action.

Provide details of the nature of the action.

Entry #2
Provide the date of the civil action. (Month/Year)

Provide the name(s) of the principal parties
involved in the court action.

Provide the court name.

Est.
Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide details of the nature of the action.

Provide a description of the results of the action.

Enter your Social Security Number before going to the next page
Page 86

Provide the name(s) of the principal parties
involved in the court action.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 27 - 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.
27.1

Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an
awareness of the organization's dedication to that end, or with the specific intent to further such activities?

YES

NO (If NO, proceed to 27.2)

Complete the following if you responded 'YES' to being or ever having been a member of an organization dedicated to terrorism, either with an awareness of
the organization's dedication to that end, or with the specific intent to further such activities.
Entry #1
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
No positions held

Provide the dates of your involvement with the organization.
From Date (Month/Year)
Present
To Date (Month/Year)
Est.
Est.

Provide all positions held in the organization, if any.

Provide all contributions made to the
organization, if any.

Provide a description of the nature of and reasons for your involvement with the
organization.

No contributions made

Entry #2
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide the dates of your involvement with the organization.
From Date (Month/Year)
To Date (Month/Year)
Present
Est.
Provide all contributions made to the
organization, if any.

Provide all positions held in the organization, if any.

Est.
No contributions made

Provide a description of the nature of and reasons for your involvement with the
organization.

Enter your Social Security Number before going to the next page
Page 87

No positions held

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 27 - Association Record - (Continued)
27.2

Have you EVER knowingly engaged in any acts of terrorism?

YES

NO (If NO, proceed to 27.3)

Complete the following if you responded 'Yes' to EVER having knowingly engaged in any acts of terrorism.
Entry #1
Describe the nature and reasons for the activity.

Provide the dates for any such activities.
From Date (Month/Year)
To Date (Month/Year)
Est.

Entry #2
Describe the nature and reasons for the activity.

Est.

Provide the dates for any such activities.
From Date (Month/Year)
To Date (Month/Year)
Est.

27.3

Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
force?

Present

Present
Est.

YES

NO (Proceed to 27.4)

Complete the following if you responded 'Yes' to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
force.
Entry #1
Provide the reason(s) for advocating acts of terrorism.

Provide the dates of advocating acts of terrorism.
From Date (Month/Year)
To Date (Month/Year)
Est.

Present
Est.

Entry #2
Provide the reason(s) for advocating acts of terrorism.

Provide the dates of advocating acts of terrorism.
From Date (Month/Year)

To Date (Month/Year)
Est.

Enter your Social Security Number before going to the next page
Page 88

Present
Est.

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 27 - Association Record - (Continued)
27.4

Have you 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 that end or with the specific intent to further such activities?

YES

NO (If NO, proceed to 27.5)

Complete the following if 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 that end or with the specific
intent to further such activities.
Entry #1
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide the dates of your involvement with the organization.
From Date (Month/Year)

To Date (Month/Year)
Est.

Provide all contributions made to the
organization, if any.

Provide all positions held in the organization, if any.

No positions held

Present
Est.

No contributions made

Provide a description of the nature of and reasons for your involvement with the
organization.

Entry #2
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide the dates of your involvement with the organization.
From Date (Month/Year)
To Date (Month/Year)
Present
Est.
Provide all contributions made to the
organization, if any.

Provide all positions held in the organization, if any.

Est.
No contributions made

Provide a description of the nature of and reasons for your involvement with the
organization.

Enter your Social Security Number before going to the next page
Page 89

No positions held

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 27 - Association Record - (Continued)
27.5

Have you EVER 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 any state of the
United States with the specific intent to further such action?

YES

NO (If NO, proceed to 27.6)

Complete the following if 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.
Entry #1
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide all positions held in the organization, if any.
Provide the dates of your involvement with the organization.
From Date (Month/Year)
To Date (Month/Year)
Present
Est.
Provide all contributions (in U.S. dollars)
made to the organization, if any.

No positions held

Est.
No contributions made

Provide a description of the nature of and reasons for your involvement with the
organization.

Entry #2
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
Country
Street
State
Zip Code
Provide all positions held in the organization, if any.
Provide the dates of your involvement with the organization.
From Date (Month/Year)
To Date (Month/Year)
Present
Est.
Provide all contributions (in U.S. dollars)
made to the organization, if any.

Est.
No contributions made

Provide a description of the nature of and reasons for your involvement with the
organization.

Enter your Social Security Number before going to the next page
Page 90

No positions held

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Section 27 - Association Record - (Continued)
27.6

Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?

YES

NO (If NO, proceed to 27.7)

Complete the following if you responded 'Yes' to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Entry #1
Describe the nature and reasons for the activity.

Provide the dates of such activities.
From Date (Month/Year)

Est.

To Date (Month/Year)

Present
Est.

Entry #2
Describe the nature and reasons for the activity.

Provide the dates of such activities.
From Date (Month/Year)

To Date (Month/Year)
Est.

27.7

Have you EVER associated with anyone involved in activities to further terrorism?

YES

Complete the following if you responded 'Yes' to having EVER associated with anyone involved in activities to further terrorism.
Entry #1
Provide explanation.

Entry #2
Provide explanation.

Enter your Social Security Number before going to the next page
Page 91

Present
Est.

NO

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS

Form approved:
OMB No. 3206 0258

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 employment
prospects, or job status, or my removal and debarment from Federal service.
Signature (Sign in ink)

Page 92

Date signed (mm/dd/yyyy)

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my
background investigation or reinvestigation to obtain any information relating to my activities, conduct and character 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, or reinvestigation, or performing
continuous vetting, to disclose the record of investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility for a public trust position.
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.
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, and 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 public trust 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.
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 85P, 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 suitability-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 is valid for five(5) years from the date signed or upon
termination of my affiliation with the Federal Government, whichever is sooner.

Signature (Sign in ink)

Date of birth

Other names used
Current street address Apt. #

Page 93

Date signed (mm/dd/yyyy)

Full name (Type or print legibly)

City (Country)

State

ZIP Code

Social Security Number
Telephone number

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST 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 5 of the Standard Form 85P with the supplemental SF 85P-S, carefully read this authorization to release
information about you, then sign and date.
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 risks, there may be times when such a condition can affect a person’s
suitability for positions of public trust with the Federal government. Seeking or receiving mental health care for personal wellness and recovery
may contribute favorably to your suitability determination. Your signature will allow the practitioner (s) to answer only those questions identified
below.
Authorization
I am seeking assignment to or retention in a public trust position. As part of the investigation process, I hereby authorize the investigator,
special agent, or duly accredited representative of the authorized Federal agency conducting my background investigation, reinvestigation,
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. 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.
I understand the information disclosed pursuant to this authorization is for use by the Federal Government only for purposes provided in the
Standard Form 85P and will no longer be subject to 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.

Signature (Sign in ink)

Date signed (mm/dd/yyyy)

Full name (Type or print legibly)

Other names used
Current street address Apt. #

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 ability to perform a
position of public trust?
YES

NO

If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
Dates of treatment?
Signature (Sign in ink)

Page 94

Practitioner name

Date signed (mm/dd/yyyy)

Standard Form 85P
Revised December 2017
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736

Form approved:
OMB No. 3206 0258

QUESTIONNAIRE FOR
PUBLIC TRUST 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
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
I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my initial background investigation and reinvestigation, or my eligibility for a public trust 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 public trust 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
public trust position.

Print Name
Signature (Sign in ink)

Page 95

Social Security Number
Date signed (mm/dd/yyyy)