Form INV Form 42 INV Form 42 Investigative Request for Personal Information

-

• •

• •

INV FORM 42 (Rev.10/19)
DEFENSE COUNTERINTELLIGENCE
AND SECURITY AGENCY (EO 13467)
F
R
0
M

7

INVESTIGATIVE REQUEST FOR
PERSONAL 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 ldent·fed 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 retum the form In the enclosed envelope.

---

_J

PRIVACY ACT STATEMENT: The Information you provide, including your identity, will be fumished 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 determining an lnd!vldual's Initial or
continued: eligibility for access to classified national security Information or assignment to positions 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 eligibility for physical or logical access to U.S.
Government systems or facilities. ROUT INE 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 re eased to the person being Investigated upon their request unless
otherwise exempt. A complete list 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/privacy-act-of-1974•system-of-records. DISCLOSURE: Disclosure Is voluntary. However,
!allure to provide DCSA access to the requested Information may result In our agency's Inability to conduct a thorough Investigation and may prevent the govemment from making
a determination or adjudication regarding the qualifications, suitability, eligibility or fitness of the person being Investigated.
If you have significant Information which you feel unable to furnish without a promise that your Identity will be kept confidential, please Indicate this In writing on the reverse side
of this form and provide only your contact Information. Providing additional Information on this form will void your request for confidentiality.
CERTIFICATION: The person we are investigating has given written consent for this Investigative Inquiry. We keep that consent on file. If a copy Is required In order to complete
this form, please Indicate this requirement In writing on the reverse.

Completion and return of this original form as soon a& po&&lble will help this person and the agency perform their duties
In a more timely and efficient manner.

- CASE NUMBER:

---------

L

CASE TYPE:

ITEM NUMBER:

FULL NAME (LAST, FIRST, MIDDLE)
OTHER NAMES USED

POSITION REQUIRING INVESTIGATION
THIS PERSON CLAIMED THE FOLLOWING:

PUBUC BUROEN STAT8"ENt. Tht pobliC roponlng - lor "10I COll•ctlon of lnfOfflllllon, 0MB 0705-00DJ, IS ntmateo to avo,ago 5 mlnutn pet_.., 1nr:l1Jdlng t"- llme tor reviOwlng int"""110nS. IN/Ching e,1tt1ng data -. gau,enng
and maintaining tho data needed, and complellng and revlowlng the COiiection of lnlom>lllon. Send""''"''"°'' ,....,,Sing,,,. buollen """"'" o, - reduction ,wggntlona to tho Dopartment ol DefenH, Wuhingtoo Hoodquut.. s.vlcel,
11 whs.mc-lleusd.mb,.dd-docl-lnlO<-matlon-eol11C11onoOnwt.,,,_, R__,s lhould be awo,e 11111 notwttlWandlng orry othtt povisian of taw, no -ahalt be oubject IO orry � lo, lalllng IO oompty with• caHectlcn of Information tin
cloel not display a .,.,._ty vllkl 0MB control nombor.

GV-· U.S. GOVERNMENT PRINTING OFFICE:2020-411·706/40614

221433-7 EXPIRATION DATE: YYYYMMDD FORM APPROVED: OMB:0705-0003