Form INV Form 41 INV Form 41 Investigative Request for Employment Data and Supervisor

- • •

• •

INV FORM 41 (Rev.10/19)
DEFENSE COUNTERINTELLIGENCE
AND SECURITY AGENCY (EO 13467)

F
R
0
M

7

INVESTIGATIVE REQUEST FOR EMPLOYMENT
DATA AND SUPERVISOR INFORMATION
U.S. GOVERNMENT USE ONLY

DEFENSE COUNTERINTELLIGENCE AND SECURITY AGENCY
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX618
BOYERS, PA 16018-0618

T
0

----------------------

INSTRUCTIONS: Your contact Information was provided by the person Identified below to assist In completing a background Investigation to help
us determine this person's eligibility for employment or security clearance. To help us make this determination, we ask that you complete all Items
on the back of this form and return the form In the enclosed envelope.

L_

_J

PRIVACY ACT S TATEMENT: The Information you provide, Including your Identity, will be furnished to the agency requesting the Investigation, other agencies as warranted, and
to the person Investigated upon his or her specific request. AUTHORITY: Section 925 of Public Law 115-91; 5 USC 301; Executive Order 13467, as amended by Executive
Order 13869; and, 5 CFR 736. PRINCIPAL PURPOSE: To obtain background Information and personal records for Investigating and detennlnlng an Individual's Initial or
continued: eligibility for access to classified national security Information or assignment to posit ons with sensitive duties, suitability for enlistment or appointment Into military
service, suitability for federal employment, fitness for assignment to work under contract for or on behalf of the government, or ellglbllity for physical or logical access to U.S.
Government systems or facilities. ROUTINE USES: The Information collected may be disclosed to DCSA personnel and shared externally with other authorized government
agency personnel as a routine use when necessary and relevant to personnel vetting Investigations, determinations, and adjudications: and, for other purposes permitted under
subsection (b) of the Privacy Act of 1974, as amended (5 USC §552a). Information obtained will also be released to the person being Investigated upon their request unless
otherwise exempt. A complete Ust of the routine uses can be found in the system of records notice for the Department of Defense Personnel Vetting Records System, "DUSDI
02-DoD" at: https://www.federalreglster.gov/documents/2018/10/17/2018-22508/prlvacy-act-of-1974-system-of-records. DISCLOSURE: Disclosure Is voluntary. However,
failure to provide OCSA access to the requ!l ragamlng the butdon estlmlto o, ,,.._ nlductlon -,ions lo the Pepartrnonl ol Dot.nee. Wah;ngtor, 1-File Typeapplication/pdfFile Modified2021-08-03File Created2020-11-05