22019 PerSIST PIV Form

PIV & PRE-SECURITY FORM PIV-HUD Form 22019

U.S. Department of Housing and Urban Development OMB control #2501-New

(For Federal Applicants, Contractors, PMFs, Volunteers, Interns) Expiration Date xx-xx-xxxx

PIV & PRE-SECURITY FORM

U.S. Department of Housing and Urban Development
(For Federal Applicants, Contractors, PMFs, Volunteers, Interns)

FEDERAL CONTRACTOR (Change) PMF VOLUNTEER INTERN

APPLICANT INFORMATION:

LAST NAME: FIRST NAME: MIDDLE NAME: POSITION TITLE:

SOCIAL SECURITY NUMBER (SSN): DATE of BIRTH (MM/DD/YY):

RESIDENCE ADDRESS: CITY: STATE: ZIP CODE: -

HOME PHONE: ( ) ALTERNATE #: ( ) E-MAIL ADDRESS:

PLACE of BIRTH (POB): Are you a U.S. CITIZEN? Yes No

If no, COUNTRY of CITIZENSHIP: NATURALIZATION CERTIFICATE #

(Country, if non-US) (City) (State) If Applicable

SPONSOR INFORMATION: (For Federal Onboarding ONLY)

LAST NAME: FIRST NAME: PHONE NUMBER: ( ) Ext.

PROGRAM OFFICE/DIVISION: LOCATION: ROOM#: DOMAIN:

ADMINISTRATIVE OFFICER: LAST NAME: FIRST NAME: PHONE NUMBER: ( )

NOT TO EXCEED DATE (MM/DD/YYYY):

COR and CONTRACT INFORMATION: (For Contractor Onboarding ONLY)

LAST NAME: FIRST NAME: PHONE NUMBER: ( ) Ext.

PROGRAM OFFICE/DIVISION: LOCATION: ROOM#: DOMAIN:

VENDOR NAME: CONTRACT NUMBER:
CONTRACT EXPIRATION DATE (MM/DD/YYYY):

WILL CONTRACTOR NEED LAN ACCESS? YES NO

WILL CONTRACTOR NEED HUD PIV CARD? YES NO

PIV CARD:

Return to HUD PIV Office, HQ Room 1101 451 ^7th Street SW, Washington, DC 20410

SEPARATION DATE: PIV CARD RETURN DATE:

Privacy Act Statement

Authority: Executive Orders: 10865, 12333, 12356, and 13764. Sections 3301 and 9101, of title 5, U.S. Code; section 2165 of title 42, U.S. Code; sections 781 to 887 of title 50, U.S. Code; parts 5, 732, and 736 of title 5, Code of Federal Regulations; and Homeland Security Presidential Directive (HSPD) 12, Policy for a Common Identification Standard for Federal Employees and Contractors, August 21, 2004. Executive Order 13488, and Executive Order 13467.

Principal Purpose: Records in the system are used to document and support decisions regarding the suitability, eligibility, and fitness for services of applicants for federal employment and contract positions to include students, interns, or volunteers to the extent that their duties require access to federal facilities, information, systems, or applications. Additionally, records may be used to document security violations, and supervisory actions taken.

Routine Use: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) and to appropriate agencies, entities, and persons for disclosures compatible with the purpose for which the records in this system were collected as set forth by Appendix I — HUD's Routine Use Inventory Notice, 80 FR 81837 (December 31, 2015), all or a portion of the records or information contained in this system may be disclosed outside HUD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: (Please see System of Record Notice (SORN) for complete list)

Disclosure: Voluntary; however failure to submit this information may result in employment denial.

SORN ID: https://www.gpo.gov/fdsys/pkg/FR-2018-05-11/pdf/2018-10103.pdf (Personnel Security Integrated System for Tracking (PerSIST); P315

STATEMENT OF BURDEN: Public reporting burden for this collection of information is estimated to average .17 hours 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.

HUD collects this information to comply with the requirements outlined in Homeland Security Presidential Directive (HSPD-12), the Federal Information Processing Standard (FIPS) 201-2, and OMB Memorandums M-05-24 and the M-19-17, which assert that all governmental agencies must implement a secure identity proofing, registration, and issuance process for identity verification, prior to granting federal and non-federal employee’s access to federally controlled facilities and/or information systems. The information being collected will be used for processing requests for Personal Identity Verification (PIV) credentials (ID Badges) for Federal employees and Federal contractors. This information is required for access to federally controlled facilities and information systems pursuant to HSPD-12. If this information is not provided, HUD will not be able to complete their identity proofing and registration process. The information being collected is protected pursuant to the Privacy Act (5 U.S.C § 552a).