INV Form 43 Investigative Request for Educational Registrar and Dean

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INV FORM 43 (Rev.10/19)
DEFENSE COUNTERINTELLIGENCE
AND SECURITY AGENCY (EO 13467)
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INVESTIGATIVE REQUEST FOR
EDUCATIONAL RECORD DATA
U.S. GOVERNMENT USE ONLY

DEFENSE COUNTERINTELLIGENCE AND SECURITY AGENCY
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX618
BOYERS, PA 1601 B-0618

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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.
PRIVACY ACT STATEMENT: The lnlormation you provide, Including your Identity, wm be furnished to the agency requesting the Investigation, other agencies as warranted,
and to the per5on 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 per50nal records for investigating and determining an Individual's lnitlal 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, suitablllty for federal employment, fitness for assignment to work under contract for or on behalf of the government, or ellg blllty for phys.cal or log"cal access to U.S.
Government systems or facilities. ROUTINE USES: The Information collected may be disclosed to DCSA personnel and shared externally w.th other authorized government
agency per50nnel as a routine use when necessary and relevant to personnel vetting investigations, determinations, and adjud cations; 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 list of the routine uses can be found in the system cf records notice for the Department of Defense Per50nnet Vetting Records System, "DUSDI
02-DoD" at: https://wwwJederalregister.gov/documents/2018/10/17/2018·22508/privacy-act-of-197 4-system-of-records. DISCLOSURE: Disclosure Is voluntary. However,
failure to provide DCSA access to the requested Information may result In our agency's Inability to conduct a thorough Investigation and may prevent the government from making
a determination or adjudication regardlng the qualificadons, su'tability, eligibility or fitness of the person being Investigated.
CERTIFICATION: The person we are lnvesdgating has given written consent for this Investigative Inquiry. We keep that consent on file. If a copy Is required In order to comp'ete
this form, please Indicate th!s requirement In writing on the rever5e.

Completion and return of this original form as soon as possible will help this person and the agency perform their duties
In a more timely and efficient manner.
CASE NUMBER:

CASE TYPE:

ITEM NUMBER:

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

DATE OF BIRTH

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SOCIAL SECURITY NUMBER

PLACE OF BIRTH

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POSITION REQUIRING INVES TIGATION

THIS PERSON CLAIMED ATTENDANCE AS FOLLOWS
TO (MO/VRI
SCHOOL NAME AND ADDRESS
FROM (MO/YR)

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DEGREE AND DATE (MO/YR)

LAST CLAIMED RESIDENCE DURING PERIOD OF ATTENDANCE

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