Form INV Form 44 INV Form 44 Investigative Request for Law Enforcement Data

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INVESTIGATIVE REQUEST FOR
LAW ENFORCEMENT DATA

INV FORM 44 (Rev.10/19)

DEFENSE COUNTERINTELLIGENCE
AND SECURITY AGENCY (EO 13467)
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U.S. GOVERNMENT USE ONLY

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

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INSTRUCTIONS: We ara conducting a background Investigation on the person identified below to determine this person's
eligibility for employment or security clearance. To help make this determination. we ask that you complete all items on the back
of this form and return the form In the enclosed envelope.

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PRIVACY ACT STATEMENT: 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 and 9101; 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 lndlvldual's Initial
or continued: eligibility for access to classified national security Information or assignment to positions with sens tlve duties, suitab;llty for enlistment or appointment Into mllltary
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. ROUTINE USES: The information collected may be disclosed t o 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 11st of the routine uses can be found In the system of records notice for the Department of Defense Personnel Veit ng Records System, "DUSO!
02-DoD" at: https://www.federalreglster.gov/documents/2018/10/17/201B-225D8/privacy-act-of-1974-system•of-f\!Cords, 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 regarding the qualifications, suitability, eligibility or fitness of the person be ng Investigated.

- The Defense Counterintelligence and Security Agency is authorized by Statute, Presidential Executive Order and Federal Regulations to make
this Investigative inquiry.
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Request covered by the Security Clearance Information Act (5 USC 9109)
Request not covered by the Security Clearance Information Act

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
PLACE OF BIRTH

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SOCIAL SECURITY NUMBER

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posmoN REQUIRING INVESTIGATION

CURRENT RESIDENCE

THIS PERSON CLAIMS THE FOLLOWING CRIMINAL HISTORY RECORD AT YOUR LOCATION
DATE (MO/YR)

DATE (MO/YRI

OFFENSE:

OFFENSE:

ACTION:

ACTION:

LAW ENFORCEMENT AUTHORITY OR COURT

CLAIMED RESIDENCE AT TIME OF OFFENSE

G :,l}· U.S. GOVERNMENT PRINTING OFFICE:2020-411-708/40614

221435-5

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