DS-7809 Law Enforcement Officers Safety Act (LEOSA) Photographic

U.S. Department of State

RETIRED/FORMER DSS LAW ENFORCEMENT OFFICER LEOSA
PHOTOGRAPHIC IDENTIFICATION CARD APPLICATION

OMB Approval No. 1405-xxxx
Expires: xx-xx-20xx
Estimated burden: xx minutes

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 establishes Department policy regarding qualified individuals who are retiring, retired,
separated, or separating from a law enforcement officer position applying for a LEOSA photographic identification card.
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. Applicant’s Full Legal Name
2. Applicant’s Telephone Number
3. Applicant’s Email Address
4. Applicant’s Residential Address
5. Applicant’s Date of Birth
6. Copy of Applicant’s Driver’s License or other Government Identification (with photograph)
7. FBI Identity History Summary Check1
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.
DS-7809
11-2021

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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.

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PART III: LEOSA PHOTOGRAPHIC IDENTIFICATION CARD APPLICATION INSTRUCTIONS
Please check the applicable boxes:
Application for replacement card 2
card

Application for new card

Retiring or separating law enforcement officer currently employed by DSS
Submit the following:
• Signed and initialed 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;
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 separating law enforcement officer NOT 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;
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).
• FBI Identity History Summary Check 3
PART IV: APPLICANT PERSONAL INFORMATION
Full Name (Last, First, Middle Initial)

Date of Birth (mm-dd-yyyy)

Residential Address (Street Address, City, State, Zip Code)

Phone Number(s) (home and cell)

Email Address

Mailing Address (if different from residential address above; no P.O. Boxes)

Law Enforcement Service History (Reverse Chronological Order)
I have more than 10 years of law enforcement
experience with DSS.

I do not have ten years of law enforcement experience with DSS and will be applying for a DSS
LEOSA Photographic Identification Card using a combination of law enforcement experience.

If you have more than 10 years of law enforcement experience with DSS you do not need to fill out the Service History section below.
1. Name of Agency

Start Date (mm-yyyy)

Job Title Upon Separation/Retirement

End Date (mm-yyyy)

Reason for leaving (retirement, separation/resignation, termination)

Comments

2. Name of Agency

Start Date (mm-yyyy)

Job Title Upon Separation/Retirement

End Date (mm-yyyy)

Reason for leaving (retirement, separation/resignation, termination)

Comments

DS-7809

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Missing DSS-issued LEOSA photographic identification cards must be reported to [email protected].
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.

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Law Enforcement Service History (Reverse Chronological Order) (continued)
3. Name of Agency

Start Date (mm-yyyy)

Job Title Upon Separation/Retirement

End Date (mm-yyyy)

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 Officers 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.
DS-7809

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PART V: SELF ATTESTATION (continued)
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).
Initials

By initialing here and signing the attestation, the applicant acknowledges his/her understanding of, and agreement with, all statements,
terms, conditions and requirements included above.

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 (mm-dd-yyyy)

PART VII: WITNESS SIGNATURE
Current DSS special agents are not required to have a witness. Former DSS special agents must have this form notarized before submission.
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.

DS-7809

Witness Signature

Date (mm-dd-yyyy)

Witness Printed Name

Title

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