Law Enforcement Officers Safety Act Photographic ID Appl

RETIRED/FORMER DSS LAW ENFORCEMENT OFFICER LEOSA
PHOTOGRAPHIC IDENTIFICATION CARD APPLICATION
PART I: PRIVACY ACT STATEMENT
This Privacy Act Statement serves to inform you of how the Diplomatic Security Service (DSS)
uses the personally identifiable information (PII) on this form.
AUTHORITY: DSS is authorized to collect and maintain the information on this form pursuant
to Title 18, United States Code § 926C, “Carrying of Concealed Firearms by Qualified Retired
Law Enforcement Officers” [Law Enforcement Officers Safety Act of 2004 (LEOSA), as
amended].
PURPOSE: DSS uses the information on this LEOSA photographic identification card
application to determine if an applicant meets the statutory criteria for issuance of a LEOSA
photographic identification card. This Application is to be completed by qualified retiring,
retired, separating, or separated law enforcement officers from DSS.
ROUTINE USES: DSS uses the information you submit on this form to adjudicate your request
for a DSS-issued LEOSA photographic identification card. More information on the Routine
Uses for the system can be found in the System of Records Notice State-36, Security Records.
DISCLOSURE: Providing this information is voluntary. Failure to provide the information
requested on this application may result in delays in considering the application or the
application’s denial.
PART II: LEOSA PHOTOGRAPHIC IDENTIFICATION CARD APPLICATION
NOTICE
Department of State Foreign Affairs Manual 12 FAM 372.6-6 establishes Department policy
regarding qualified individuals who are retiring, retired, separated, or separating from a law
enforcement officer position.
DSS will not reimburse the applicant for any expenses (e.g., Federal Bureau of Investigation
(FBI) Identity History Summary check, notary fees, etc.) incurred as a result of submitting this
application.
How Do I Submit My Application?
Completed LEOSA photographic identification card application packages may be emailed to
[email protected].
Completed application packages may also be mailed to:

Domestic Facilities Protection Credential Office, c/o LEOSA
U.S. Department of State, SA-9
2025 E St. NW, Washington, DC 20006
Incomplete application packages will not be processed.
In order for the DS Office of Domestic Facilities Protection (DS/DO/DFP) to process your
LEOSA photographic identification card application, the following information is required:
1.
2.
3.
4.
5.
6.

Applicant’s Full Legal Name
Applicant’s Telephone Number
Applicant’s Email Address
Applicant’s Residential Address
Applicant’s Date of Birth
Copy of Applicant’s Driver’s License or other Government Identification (with
photograph)
7. FBI Identity History Summary Check 1
8. Copy of Applicant’s SF-50, or Similar Documentation, Establishing Applicant’s
Eligibility for a LEOSA Photographic Identification Card
NOTE: LEOSA photographic identification cards will only be mailed to residential addresses.
Replacement for Lost or Stolen LEOSA Photographic Identification Cards
Obtaining a new LEOSA photographic identification card requires submission and review of a
new LEOSA photographic identification card application package, containing current applicant
information and supporting materials.
If a prior LEOSA photographic identification card is lost or stolen, report the card missing to
[email protected] and indicate on any subsequent LEOSA photographic
identification card application that the application is for a replacement card.
PART III: LEOSA PHOTOGRAPHIC IDENTIFICATION CARD APPLICATION
INSTRUCTIONS
Please check the applicable boxes:
□ Application for new card

□ Application for replacement card 2

1
The FBI Identity History Summary Check must be obtained within the 60 days prior to this application’s
submission and submitted with all other required documentation. Applications submitted with an FBI Identity
History Summary Check that includes processing dates in excess of 60 days will be rejected.
2
Missing DSS-issued LEOSA photographic identification cards must be reported to
[email protected].

□ Retiring or separating law enforcement officer currently employed by DSS
Submit the following:
• Signed, initialized, and witnessed/notarized DSS LEOSA Photographic
Identification Card Application;
• Two current photographs following the CA Passport Photo Requirements;
• Documentation evidencing an aggregate of 10 or more years of law enforcement
officer service;
o If aggregate service includes time with another law enforcement agency, you
must also submit documentation of employment and good standing from that
agency;
• Copy of driver’s license or other Government identification (with photograph).
□ Retired or separated law enforcement officer
Submit the following:
• Signed, initialized, and witnessed/notarized DSS LEOSA Photographic
Identification Card Application;
• Two current photographs following the CA Passport Photo Requirements;
• Documentation evidencing an aggregate of 10 or more years of law enforcement
officer service;
o If aggregate service includes time with another law enforcement agency, you
must also submit documentation of employment and good standing from that
agency;
• Copy of driver’s license or other Government identification (with photo).
• FBI Identity History Summary Check 3
PART IV: APPLICANT PERSONAL INFORMATION
Full Name (Last, First, Middle Initial): _____________________________________________
Date of Birth: __________________________________________________________________
Residential Address (Street Address, City, State, Zip Code): _____________________________
______________________________________________________________________________
Phone Number(s) (home and cell): _________________________________________________
Email Address: _________________________________________________________________

The FBI Identity History Summary Check must be obtained within the 60 days prior to this application’s
submission and submitted with all other required documentation. Applications submitted with an FBI Identity
History Summary Check that includes processing dates in excess of 60 days will be rejected.
3

Mailing Address (if different from residential address above; no P.O. Boxes): _______________
______________________________________________________________________________
Law Enforcement Service History (Reverse Chronological Order)
1. Name of Agency: _____________________________________________________________
Job Title: _____________________________________________________________________
Start Date: ____________________________________________________________________
End Date: _____________________________________________________________________
Reason for leaving (retirement, separation/resignation, termination): ______________________
Comments: ____________________________________________________________________
______________________________________________________________________________

2. Name of Agency: _____________________________________________________________
Job Title: _____________________________________________________________________
Start Date: ____________________________________________________________________
End Date: _____________________________________________________________________
Reason for leaving (retirement, separation/resignation, termination): ______________________
Comments: ____________________________________________________________________
______________________________________________________________________________

3. Name of Agency: _____________________________________________________________
Job Title: _____________________________________________________________________
Start Date: ____________________________________________________________________

End Date: _____________________________________________________________________
Reason for leaving (retirement, separation/resignation, termination): ______________________
Comments: ____________________________________________________________________
______________________________________________________________________________

NOTE: If additional space is needed, please attach a separate piece of paper including the
requested information for each additional position.
PART V: SELF ATTESTATION
By initialing each item below and signing the attestation, the applicant acknowledges his/her
understanding of, and agreement with, all statements, terms, conditions, and requirements
included herein:
1. I am submitting this application for a LEOSA photographic identification card
identifying me as a qualified retired law enforcement officer who retired or separated
from DSS in good standing. ________
2. I understand that any cost incurred as a result of applying for a LEOSA photographic
identification card, including the cost of obtaining an annual State firearms testing
certification, is the sole responsibility of the applicant, and DSS will not reimburse the
applicant for any costs associated with this application. ________
3. I have read and fully understand 18 U.S.C. § 926C, “Carrying of Concealed Firearms by
Qualified Retired Law Enforcement Officers” [Law Enforcement Officer Safety Act of
2004 (LEOSA), as amended]. ________
4. I meet the following requirements set out in LEOSA, 18 U.S.C. § 926C, of a “qualified
retired law enforcement officer” in that I:
a. Before such retirement or separation from DSS, was authorized by law to engage in or
supervise the prevention, detection, investigation, or prosecution of, or the
incarceration of any person for, any violation of law and had statutory powers of
arrest; ________
b. Before such retirement or separation from DSS, was regularly employed as a law
enforcement officer for an aggregate total of 10 years or more; ________

i. Alternatively, I retired or separated (or am about to retire or separate) from
service with DSS, after completing any applicable probationary period,
due to a service-connected disability (as determined by the State
Department); ________
c. During the most recent 12-month period, have met, at my expense, the standards for
qualification in firearms training for active law enforcement officers, as determined by
DSS, my State of residence, or, if my State has not established such standards, either a
law enforcement agency within my State of residence or the standards used by a
certified firearms instructor qualified to conduct a firearms qualification test for active
duty officers within my State; ________
d. Have not been officially found, by a qualified medical professional employed by the
State Department, to be unqualified for reasons relating to mental health and have not
entered into an agreement with the State Department in which I acknowledged I am
not qualified for reasons relating to mental health; ________
e. Am not under the influence of alcohol or another intoxicating or hallucinatory drug or
substance; ________
f. Am not prohibited by Federal law (18 U.S.C. § 922) from receiving or possessing a
firearm; and ________
g. At the time of my retirement or separation, was deemed to be in “good standing”
under the provisions of 12 FAM 372.6-6. ________
5. I authorize the State Department to review my personnel records, external records, and/or
any internal agency reports of investigation or management inquiries that may affect my
fitness to carry a firearm. ________
6. I authorize DSS to release information in its possession (to the extent it is relevant to my
fitness to carry a firearm) in the event that additional information is requested of it,
regarding my fitness to carry a firearm, by the entity or person certifying my firearms
qualification. ________
7. By initialing this paragraph, I waive all Privacy Act and other legal rights and remedies
against the disclosure described in Part V, Number 6, and indemnify DSS and hold it
harmless against any liability for such release. ________
8. I understand that DSS will not conduct or assist with any annual firearms testing for
retirees or separated employees. I understand that LEOSA requires me to obtain a
certification issued by the State in which I reside indicating that I meet State training and

qualification standards for active law enforcement officers to carry a firearm. I
understand I must annually complete this certification within the one year prior to the
date I am carrying a firearm. The availability of such certifications varies by State, and it
is my responsibility to determine and meet the requirements of my State of residence for
obtaining this certification. _________
9. I understand that I must have my DSS-issued LEOSA photographic identification card
identifying me as a retired or separated law enforcement officer AND my up-to-date
annual State firearms testing certification on my person at all times when I carry a
concealed firearm under the authority of LEOSA. Possession of my DSS-issued LEOSA
photographic identification card alone does not authorize me to carry a concealed
firearm. ________
10. I understand that, in order to carry a concealed firearm under the authority of LEOSA, it
is my responsibility to ensure that I am in continuing compliance with all LEOSA
requirements. If at any time I no longer meet any one of LEOSA’s requirements, or
become subject to a Federal law prohibition on carrying a firearm (18 U.S.C. § 922), I
must notify DSS and the certifying entity in my State of residence, and I will no longer be
eligible to carry a concealed firearm under the authority of LEOSA. ________
11. I understand that the LEOSA photographic identification card is ONLY for the purpose
of identifying me as a retired or separated law enforcement officer. ________
12. Neither the DSS-issued LEOSA photographic identification card nor LEOSA confer law
enforcement status or arrest authority. I understand that carrying a DSS-issued LEOSA
photographic identification card does not authorize me to engage in any law enforcement
activities or investigations. ________
13. I understand that, upon my retirement/separation, I am no longer a law enforcement
officer with DSS. As such, DSS will not represent or reimburse me in any suit or claim
related to my carrying a concealed firearm under LEOSA authority. ________
14. In consideration for the issuance of a LEOSA photographic identification card, I agree to
indemnify and hold the U.S. Government, DSS, and their officers and employees
harmless from any and all claims and liability arising out of my use of or possession of a
firearm carried under LEOSA authority. In addition, I, and my heirs, executors, or
administrators, release and forever discharge the U.S. Government, DSS, and their
officers and employees from any and all claims, demands, or causes of action related to
my use or possession of a firearm or DSS’s issuance of a LEOSA photographic
identification card. ________
15. I understand that, with certain limitations and conditions, LEOSA exempts qualified
retired and separated law enforcement officers from most State and local laws that

prohibit the carriage of concealed firearms. However, I also understand that LEOSA
does not supersede or limit State laws that permit private persons or entities to prohibit or
restrict the possession of concealed firearms on their property and that LEOSA does not
limit State laws that prohibit or restrict the possession of firearms on any State or local
government property, installation, building, base, or park. ________
16. I understand that LEOSA does not exempt qualified retired or separated law enforcement
offices from Federal laws or regulations, including any restrictions on carrying firearms
on transportation systems, including commercial airlines. I understand that possession of
my DSS-issued LEOSA photographic identification card and up-to-date annual State
firearms testing certification does not authorize me to carry a concealed firearm in the
cabin of a commercial aircraft. ________
17. I understand that the issuance of a LEOSA photographic identification card is within the
discretion of DSS and is dependent on DSS’s determination that I am a qualified retired
law enforcement officer as defined by law. Any photographic identification card issued
by DSS is the property of DSS. Loss of the identification must be immediately reported
to DSS. Alteration, reproduction, or copying of the identification is prohibited. The
identification must be surrendered upon request. Misuse or failure to comply with any
terms or requirements set out in this document may result in revocation of the
identification. Submitting false or misleading information with this application may
result in denial of the application or revocation of a previously issued identification card
and referral of that information to the appropriate law enforcement agency. ________
18. I was not removed from federal law enforcement service, I did not resign or retire from
federal law enforcement service after being told that I would be fired, I did not leave
federal law enforcement service by mutual agreement because of specific problems, and I
was not prohibited from federal employment by the Office of Personnel Management or
any other federal agency. ________
19. I am not under indictment or charges for any violation of law. ________
20. I have not been convicted of any crime, nor been subject to any court order, regarding
domestic violence, as outlined in 8 U.S.C. §§ 922(g)(8) and 922(g)(9). ________
PART VI: APPLICANT ACKNOWLEDGEMENT
I, ____________________________________ (applicant’s full name), confirm my
understanding of, and agreement with, the statements and requirements included above. All of
the information I have included in this DSS LEOSA photographic identification card application
(and accompanying attachments) is accurate to the best of my knowledge.

I declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct, and that I am the person named above (applicant) and I understand
any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a
fine or by imprisonment of not more than five years or both, and that requesting or obtaining any
record(s) under false pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a
fine of not more than $5,000.
_______________________________________________
Signature

______________
Date

PART VII: WITNESS SIGNATURE
Witness signature must be the applicant’s current DSS supervisor or a Notary Public.
The above named applicant, __________________________________, appeared before me in
person on ___________ and signed this Application in my presence, and I verified his/her
identity via a government issued photographic identification.
_______________________________________________
Witness Signature
__________________________________________
Witness Printed Name

______________
Date
______________________________
Title