Form INV 100 INV 100 FREEDOM OF INFORMATION / PRIVACY ACT RECORDS REQUEST FOR

OMB No. 0705-0001
OMB approval expires
November 30, 2020

FREEDOM OF INFORMATION / PRIVACY ACT RECORDS REQUEST
FOR BACKGROUND INVESTIGATIONS

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to
the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT
Authorities: 5 U.S.C. 552, 5 U.S.C. 552a, 32 CFR 310, and 32 CFR 286.
Principal Purpose(s): The purpose of the collection is to enable the DCSA – Defense Counterintelligence and Security Agency – to locate applicable
records and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974.
Routine Use(s): The information collected on this form will primarily be used to comply with requests for information under
5 U.S.C. § 552 and 5 U.S.C. § 552a. The information requested may be used by and disclosed to DCSA personnel, contractors, and/or shared
externally with other government agency personnel as a routine use when necessary and relevant to assist in activities related to the processing of
your Freedom of Information Act and/or Privacy Act request. Additionally, DCSA may use the information as necessary and authorized by the routine
uses in the system of records notice associated with this form:
V1-01: Privacy and Freedom of Information Request Records. A complete list of the routine uses and the full text of V1-01 can be found at:
https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570278/v1-01/.
Disclosure: Information Regarding Disclosure of your Social Security Number (SSN) under Public Law 93-579, Section 7 (b). Solicitation of SSNs by
DCSA is authorized under the provisions of Executive Order 9397, dated November 22, 1943. Providing your social security number is voluntary. You
are asked to provide your social security number only to facilitate the identification of records relating to you. Without your social security number,
DCSA may be unable to locate records pertaining to you. The use of SSNs is necessary because of the large number of Federal employees,
contractors, civilians and military personnel who have identical names and/or birth date and whose identities can only be distinguished by their SSNs.
INSTRUCTIONS
Use of this form is optional. To request a copy of your investigative records, please complete the appropriate fields below (or send a written request,
containing the below information) to our Boyers, PA, office location. The information you provide will be used to identify/retrieve records pertaining to
your request. Your completed form or written request, along with two forms of identification, may be submitted via mail or by secure e-mail as a
scanned attachment. If submitting via e-mail, you should ensure that the security of your e-mail system is adequate for transmitting sensitive
information before choosing to transmit your request, which contains your personally identifiable information. See page 3 for our contact information
and a list of identity source documents.
1. TYPE OF REQUEST – SELECT ALL THAT APPLY. (THIS SECTION MUST BE COMPLETED)
Privacy Act/FOIA Request – I request my own records. (Requester must complete sections 2, 3, 4, 5, and 7)
FOIA Request – I am making a request for records about someone or something other than myself. (Requester must complete section 2, 3, 7, and 8)
Privacy Act Amendment Request – I wish to amend my own records. In accordance with 32 C.F.R.§ 310.7, include an explanation why the record
is not accurate, timely, relevant, or complete without this correction, and factual documentation that supports the request for the amendment.
Requestors should attach additional material to this form. (Requestor must complete sections 2, 4, 5, and 7)
2. REQUESTER'S INFORMATION
FULL NAME

STREET ADDRESS

CITY

STATE

COUNTRY

ZIP CODE

TELEPHONE (optional)

PREFERRED DELIVERY METHOD
SECURE E-MAIL*
HARDCOPY MAIL
*A secure e-mail ensures that the information being sent to you is encrypted and therefore cannot be intercepted and read.

INV 100, MAR 2020

Page 1 of 3

3. RECORDS REQUESTED (Select the specific records you are seeking)
Standard Form Only (SF86, 85P, or 85)

All investigations and Standard Forms

Most Recent Investigation (including Standard Form)

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

4. REQUESTOR’S IDENTIFYING INFORMATION (complete this section only if you are making a request for records about yourself.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
STATE OF BIRTH

CITY OF BIRTH

COUNTRY OF BIRTH

5. IDENTITY SOURCE DOCUMENTS - (Copies of two identity source documents must be submitted along with this form)
Examples of acceptable identity source documents are provided on page 3 of this form.
Copies of two identify source documents are attached.
6. AUTHORIZATION TO RELEASE INFORMATION TO THIRD PARTY (optional)
By completing this section, you authorize information relating to you to be released to another person, such as a family member or legal counsel.
Please note, if you choose to have your records sent to a third party, you will not be furnished a duplicate copy. Pursuant to 5 U.S.C.
§ 552a(b), I authorize the DCSA - Defense Counterintelligence and Security Agency - to release my records (defined above) to:
FULL NAME

MAILING ADDRESS

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

INV 100, MAR 2020

DATE

Page 2 of 3

8. COMPLETE THIS SECTION ONLY IF YOU ARE REQUESTING RECORDS ABOUT SOMEONE OR SOMETHING OTHER THAN YOURSELF
In the box below, you may wish to provide information about yourself and the purpose of your request to help us determine your fee category. While
FOIA does not require a requester to state the purpose of a request, fees may be reduced based on the nature of the requester or purpose of the
request. Fees for searching, copying, and processing records in this category may be levied in accordance with DCSA's regulations at 32 C.F.R.
286.12. If you are asking for a waiver or reduction of fees, you can also use this box to provide an explanation. Attach a separate page if you need
more space than provided below.

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

Mail
Defense Counterintelligence and Security Agency
ATTN: FOIA and Privacy Office for Investigations
1137 Branchton Road, P.O. Box 618
Boyers PA 16018

E-mail: [email protected]
Fax: (724) 794-4590

IDENTITY SOURCE DOCUMENTS

All identity source documents provided by a requester must be the individual's own, and the ID must be current (not expired, nor canceled). The two
identity source documents must bear the same name. Do not send original documents; send in only legible copies. Acceptable documents include the
following:















U.S. Social Security Card issued by the Social Security Administration
U.S. Passport or a U.S. Passport Card
Driver's license or an ID Card issued by a state or possession of the United States, provided it contains a photograph (Student ID Cards are
not acceptable)
U.S. Military ID Card or CAC Card
U.S. Military Dependent's ID Card
PIV Card
Copy of a birth certificate issued by a state, county, municipal authority, possession, or outlying possession of the United States, bearing an
official seal
Certification of Birth Abroad or Certification of Report of Birth issued by the Department of State (Form FS-545 Or Form DS-1350)
Voter Registration Card from the U.S.
Permanent Resident Card or an Alien Registration Receipt Card (Form I-551)
Certificate of U.S. Citizenship (Form N-560 or N-561)
Certificate of Naturalization (Form N-550 Or N-570)
Employment Authorization Document issued by the Department of Homeland Security (Form I-688A, Form I-688B or Form I-766)
U.S. Citizen ID Card (Form I-197)

INV 100, MAR 2020

Page 3 of 3