Form SF 85 SF 85 Questionnaire for Non Sensitive Positions

SF 85 Questionnaire for Non-Sensitive Positions

Draft SF 85 Content Guide _ 30 Day Notice v7_ mock up

SF 85 Questionnaire for Non-Sensitive Positions

OMB: 3206-0261

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Draft version 7 (December 2017)

Questionnaire for Non-Sensitive Positions
OMB No. 3206–0261
Form: SF 85

Interactive/Branching
Electronic Questionnaire

Questionnaire Content Guide

(DRAFT for 30 Day Notice)
FOR REFERENCE ONLY
NOT A FORM FOR COMPLETION

Draft version 7 (December 2017)

General Electronic Form Notes/Notices (all Sections)
The questions/content captured in this document are intended to display what data will be captured from the subject and the additional questions
to be presented based on the subject’s responses to previous questions during data capture.
Question numbering and “electronic form navigation notes” have been made throughout this form to help facilitate review and navigation. These
items are subject to change based on the data collection or processing systems this form may be implemented in. Additionally numbering and
electronic form notes are not to be considered part of the content of the form. Only the section numbers are applicable as the official numbering
for this form.
Screens may vary based on html style formatting, java scripting, data capture formatting, system functionality, validation, and navigation.
Systems that are used for the collection of the “Questionnaire for Non-Sensitive Positions (SF 85)” data for investigative purposes are subject to
OMB review and approval.
Dropdown lists throughout this form (such as listings of countries, document types, etc.) are subject to change based on changes or requirements
of federal information processing standards and other updates/changes to pertinent information collection, consistent with approved content.

Draft version 7 (December 2017)

OFFICE OF PERSONNEL MANAGEMENT
Questionnaire for Non-Sensitive Positions, SF 85
Questionnaire for Non-Sensitive Positions
Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.
All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties
for inaccurate or false statements are discussed below. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully
could result in an adverse personnel action against you, including loss of employment; with respect to Sections 18 and 21, however, neither your truthful responses nor information
derived from those responses will be used as evidence against you in a subsequent criminal proceeding.
Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, nonsensitive positions as defined in 5 CFR 731. This form may also be used by agencies in determining whether a subject should be issued a Federal credential for access to federally
controlled facilities and information systems . For applicants, this form is to be used only after a conditional offer of employment has been made, unless OPM has provided for an
exception. This form is not to be used for National Security sensitive positions.
Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely
affect your eligibility for a position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information provided be true
and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and duties, and
consistency with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for positions, physical and /or logical access
required to perform duties, or your ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your
eligibility for physical and logical access to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect
your employment prospects and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.
This form may become is a permanent document that may be used as the basis for future investigations, determinations of suitability or fitness for Federal employment, fitness for
contract employment, or eligibility for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your
responses to previous SF 85 questionnaires.
The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and
efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, Social Security Number,
and date and place of birth.
Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders13764, 13741, 10577, 13467, and 13488;
sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations (CFR).
Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay
the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397, as amended by EO 13478.
The Investigative Process
Background investigations for non-sensitive positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and will
not present an unacceptable risk,. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation.
The investigation may extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although
you may have previously indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or credit
report file and a credit report is required by the agency requesting your investigation, then we may not be able to complete your investigation, which can adversely affect your eligibility
for positions, physical and /or logical access required to perform duties, or your ability to obtain Federal or contract employment. To avoid such delays, you must request that the
consumer reporting agencies lift the freeze in these instances.
In addition to the questions on this form, inquiry also is made about your adherence to security requirements, your honesty and integrity, falsification, misrepresentation, and any other
behavior, activities, or associations that tend to demonstrate a person is not reliable or trustworthy, or poses an unacceptable risk to the life, safety, or health of employees, contractors,
vendors or visitors to a Federal facility; the Government’s physical assets or information systems; personal property; records, or, the privacy of the individuals whose data the
Government holds in its systems. After an eligibility determination is made, you may also be subject to reinvestigations to ensure your continuing suitability for employment.
The information you provide on this form may be confirmed during the investigation, and may be used for identification purposes throughout the investigation process.
Your Personal Interview
Some investigations may include an interview with you as needed as part of the investigative process. The investigator may ask you to explain your answers to any question on this
form. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often assists in completing your investigation. If contacted, it
is imperative that the interview be conducted as soon as possible after contact is made by the investigator. Postponements will delay the processing of your investigation, and declining
to be interviewed may result in your investigation being delayed or canceled.
For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to verify your identity, as
instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be
asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention.
Instructions for Completing this Form
1. Follow the instructions provided to you, by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form.
You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.
2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise
noted.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country dropdown
feature.
4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be provided. For locations outside of the U.S. and its territories, select
the country in the "Country" dropdown list and leave the "State" field blank.
5. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with completing
the Zip Codes.
6. For telephone numbers in the U.S., ensure that the area code is included.
7. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the dropdown lists to select the month and day. The year should be entered as a four character
number (i.e. 1978 or 2001.), or selected from a dropdown list. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate this by
checking the "Est." box.
Final Determination on Your Eligibility
Final determination on your eligibility for a position and/or physical or logical access to federal facilities and information is the responsibility of the Office of Personnel Management or
the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made, if an
unfavorable decision is considered. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex
(including pregnancy and gender identity), national origin, disability, and sexual orientation, when making determinations of eligibility for non-sensitive positions, physical and/or
logical access required to perform duties.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to five (5) years
imprisonment. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent
record for future placements. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any

Draft version 7 (December 2017)
information you provide on this form and to make your comments part of the record.
Disclosure Information
The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and
disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have
published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information
collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C.
552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. The office that gave you this form will provide you a copy of its routine uses.
You will not receive prior notice of such disclosures under a routine use.
In addition to those disclosures generally permitted under the Privacy Act, all or a portion of the records or information you provide on this form or during your
investigation may be disclosed outside of OPM as a routine use as outlined below.
Privacy Act Routine Uses
Common Routine Uses
The Privacy Act routine uses of agencies conducting or requesting investigations, or with authorized custody over your investigative information, commonly
include some or all of the following:
1.
To the Department of Justice when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the
agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government, is a party to litigation
or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records
by the Department of Justice is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.
2.
To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c0
any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government
is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and
the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.
3.
Except as noted in Question 14, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal,
or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may be
disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged
with enforcing or implementing the statute, rule, regulation, or order.
4.
To any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other
personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the
source of the nature and purpose of the investigation, and to identify the type of information requested.
5.
To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of any employee, or the
retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written
consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support
a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action.
6.
To contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged.
Such recipients shall be required to comply with the Privacy Act of 1974, as amended.
7.
To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted
invasion of personal privacy.
8.
To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable
an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or
any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such
statutes, orders or directive.
9.
To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about
whom the record is maintained.
10.
To the National Archives and Records Administration for records management inspections conducted under 44 USC 2904 and 2906.
11.
To the Office of Management and Budget when necessary to the review of private relief legislation.
a. To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government or the Government
of the District of Columbia having a need to investigate, evaluate, or make a determination regarding loyalty to the United States; qualifications, suitability, or fitness for Government
employment or military service; eligibility for logical or physical access to federally-controlled facilities or information systems; eligibility for access to classified information or to
hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.
b. To an element of the U.S. Intelligence Community as identified in E.O. 12333, as amended, for use in intelligence activities for the purpose of protecting United States national
security interests.
c. To any source from which information is requested in the course of an investigation, to the extent necessary to identify the individual, inform the source of the nature and purpose of
the investigation, and to identify the type of information requested.
d. To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or
order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.
e. To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with its current
employee’s, contractor employee’s, or military member’s retention; loyalty; qualifications, suitability, or fitness for employment; eligibility for logical or physical access to federallycontrolled facilities or information systems; eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the
Government under contract, grant, or other agreement; or access to restricted areas.
f. To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from
the subject of the investigation.
f.
g. To disclose information to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government.
h. For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative
support.
i. To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.
j. To appropriate agencies, entities, and persons when (1) OPM suspects or has confirmed that there has been a breach of the system of records; (2) OPM has determined that as a
result of the suspected or confirmed breach there is a risk of harm to individuals, the agency (including its information systems, programs and operations), the Federal Government, or
national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with OPM’s efforts to respond to the suspected or
confirmed breach or to prevent, minimize, or remedy such harm.
k. To another Federal agency or Federal entity, when OPM determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in
(1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the agency (including its information systems, programs
and operations), the Federal Government, or national security, resulting from a suspected or confirmed breach.
l. To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, when the
Government is a party to the judicial or administrative proceeding. In those cases where the Government is not a party to the proceeding, records may be disclosed if a subpoena has
been signed by a judge.
m. To disclose information to the National Archives and Records Administration for use in records management inspections.
n. To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which OPM is authorized to appear,

Draft version 7 (December 2017)
when:
(1)
OPM, or any component thereof; or
(2)
Any employee of OPM in his or her official capacity; or
(3)
Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or
(4)
The United States, when OPM determines that litigation is likely to affect OPM or any of its components;
is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OPM is deemed by OPM to be relevant and necessary to the
litigation, provided, however, that the disclosure is compatible with the purpose for which records were collected.
o. For the Merit Systems Protection Board--To disclose information to officials of the Merit Systems Protection Board or the Office of the Special Counsel, when requested in
connection with appeals, special studies of the civil service and other merit systems, review of OPM rules and regulations, investigations of alleged or possible prohibited personnel
practices, and such other functions, e.g., as promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by law.
p. To disclose information to an agency Equal Employment Opportunity (EEO) office or to the Equal Employment Opportunity Commission when requested in connection with
investigations into alleged or possible discrimination practices in the Federal sector, or in the processing of a Federal-sector EEO complaint.
q. To disclose information to the Federal Labor Relations Authority or its General Counsel when requested in connection with investigations of allegations of unfair labor practices or
matters before the Federal Service Impasses Panel.
r. To another Federal agency’s Office of Inspector General when OPM becomes aware of an indication of misconduct or fraud during the applicant’s submission of the standard forms.
s. To another Federal agency’s Office of Inspector General in connection with its inspection or audit activity of the investigative or adjudicative processes and procedures of its agency
as authorized by the Inspector General Act of 1978, as amended, exclusive of requests for civil or criminal law enforcement activities.
t. To a Federal agency or state unemployment compensation office upon its request in order to adjudicate a claim for unemployment compensation benefits when the claim for benefits
is made as the result of a qualifications, suitability, fitness, security, identity credential, or access determination.
u. To appropriately cleared individuals in Federal agencies, to determine whether information obtained in the course of processing the background investigation is or should be
classified.
v. To the Office of the Director of National Intelligence for inclusion in its Scattered Castles system in order to facilitate reciprocity of background investigations and security
clearances within the intelligence community or assist agencies in obtaining information required by the Federal Investigative Standards.
w. To the Director of National Intelligence, or assignee, such information as may be requested and relevant to implement the responsibilities of the Security Executive Agent for
personnel security, and pertinent personnel security research and oversight, consistent with law or executive order.
x. To Executive Branch Agency insider threat, counterintelligence, and counterterrorism officials to fulfill their responsibilities under applicable Federal law and policy, including but
not limited to E.O. 12333, 13587 and the National Insider Threat Policy and Minimum Standards.
y. To the appropriate Federal, State, local, tribal, foreign, or other public authority in the event of a natural or manmade disaster. The record will be used to provide leads to assist in
locating missing subjects or assist in determining the health and safety of the subject. The record will also be used to assist in identifying victims and locating any surviving next of kin.
z. To Federal, State, and local government agencies, if necessary, to obtain information from them which will assist OPM in its responsibilities as the authorized Investigation Service
Provider in conducting studies and analyses in support of evaluating and improving the effectiveness and efficiency of the background investigation methodologies.
aa. To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with the
classifying of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to
the requesting agency’s decision on the matter.

STATE CODES (ABBREVIATIONS)
Alabama AL, Alaska AK, Arizona AZ, Arkansas AR, California CA, Colorado CO, Connecticut CT, Delaware DE, District of Columbia DC, Florida FL, Georgia GA, Hawaii HI,
Idaho ID, Illinois IL, Indiana IN, Iowa IA, Kansas KS, Kentucky KY, Louisiana LA, Maine ME, Maryland MD, Massachusetts MA, Michigan MI, Minnesota MN, Mississippi MS,
Missouri MO, Montana MT, Nebraska NE, Nevada NV, New Hampshire NH, New Jersey NJ, New Mexico NM, New York NY, North Carolina NC, North Dakota ND, Ohio OH,
Oklahoma OK, Oregon OR, Pennsylvania PA, Rhode Island RI, South Carolina SC, South Dakota SD, Tennessee TN, Texas TX, Utah UT, Vermont VT, Virginia VA, Washington
WA, West Virginia WV, Wisconsin WI, Wyoming WY American Samoa AS, Guam GU, Northern Mariana Islands MP, Puerto Rico PR, Virgin Islands of the U.S. VI
Public Burden Information
Public burden reporting for this collection of information is estimated to average 120 minutes per response, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to U.S. Office of Personnel Management, National Background Investigations Bureau, Attn: OMB Number
3206-0261 1900 E Street, NW, Washington, DC 20415. The OMB clearance number, 3206-0261, is currently valid. OPM may not collect this information, and you are not required to
respond, unless this number is displayed.
--------------------END OF INSTRUCTION PAGES -------------------

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the
penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal
YES NO
Service.

Agency Use Block “AUB”
Investigating agency user only
Codes:
(FIPC CODES)
Case Number:
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: AS A REMINDER, AGENCIES ARE RESPONSIBLE FOR REVIEWING
INFORMATION PROVIDED ON THE OF 306, RESUME, AND OTHER DOCUMENTATION PROVIDED AS PART OF THE HIRING
PROCESS TO IDENTIFY POSSIBLE DISCREPANCIES WITH INFORMATION PROVIDED ON THE STANDARD FORM
QUESTIONNAIRE. AGENCIES MUST NOTIFY THEIR INVESTIGATIVE SERVICE PROVIDER OF ANY DISCREPANCIES THAT MAY
EXIST BETWEEN THE FORMS, AND REQUEST RESOLUTION OF THE CONFLICT THROUGH THE INVESTIGATION PROCESS. IN
THIS SITUATION THE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
A – Type of Investigation
B – Extra coverage / advanced results
C –Risk level
D – Nature of action code
E – Date of action
F – Geographic location
G – Position code
H – Position title
I – SON (Submitting Office Number )
J – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other
Other address / web address of e-OPF
Zip Code
K – SOI (Security Office Identifier)
L – Location of Security Folder _ None _ NPI _ At SOI _e-OPF _ Other
Other address
Zip Code
M – IPAC
N – TAS
O – Obligating document number
P - BETC
Q – Accounting data and /or Agency case number
R – Investigative requirement _Initial _Reinvestigation
S – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date
T – Secondary Requesting Official: Name, Title, Email Address, Telephone Number

Draft version 7 (December 2017)
U – Applicant Affiliation _ FED CIV _ CON _ MIL _ Other
V – Deployment/PCS (if Imminent):
From Est.-To Dates, Est., Permanent Relocation, Reason(s) for temporary duty assignment or PCS, point of contact at location, Telephone number
(Include Ext.), Address/Unit/Duty location (Include City or Post Name)
Agency Special Instructions for the Investigative Service Provider:
Cage Code
Contracting Number

Beginning of Questionnaire

FOR REFERENCE ONLY, NOT A FORM FOR COMPLETION
Section 1 – Full Name
Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you
do not have a middle name, indicate “No Middle Name”. If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last

First

Middle

Suffix

Section 2 – Date of Birth
Provide your date of birth.

Date _ _-_ _-_ _ _ _ Est. □

Section 3 – Place of Birth
Provide your Place of birth.

City

County

State

Country

Section 4 – SSN
Provide your U.S. Social Security Number.

□ Not applicable _ _ _-_ _-_ _ _ _

Section 5 – Other Names Used
Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by a former marriage (s), former name(s),
alias (es), or nickname(s)). If the other name is your maiden name, put “nee” in front of it.
Have you used any other names?
YES
NO
Provide your other name used and the period of time you used it [for example: your maiden name, name by a former marriage, former
Branch
name, alias, or nickname]. If you have only initials in your name, provide them and indicate “Initial only.” If you do not have a middle
If Yes to
name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
“Other
Provide other name used.
Last
First
Middle
Suffix
Maiden name?
Yes
No
Names”
Provide dates used.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple
Provide the reason(s) why the name changed.
Reason: (Free Text)
Entries
Summary of other names used:
Allowed)
Do you have additional names to enter?
Yes (Yes adds another entry)
No (Required to pass validation)

Section 6 – Your Identifying Information
Provide your Identifying Information

Height

(feet)

(inches)

Weight (in pounds)

Hair Color

Eye Color

Sex (M/F)

Section 7 – Your Contact Information
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background
investigation.
Provide your contact information.
Home email address
Email (Free Text)
Work email address
Email (Free Text)
Email addresses may be used as a
contact method, and identify subject
in records.
Home telephone number
Work telephone number
Mobile/Cell telephone number
Extension Time Day Night Both
Extension Time Day Night Both
Extension Time Day Night Both
__Check box if International or DSN __Check box if International or DSN
__Check box if International or DSN
phone number
phone number
phone number

Section 8 – U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
YES
NO
Provide the following information for the most recent U.S. passport you currently possess:
Provide your U.S. passport number
Passport (Free Text)
Branch
Click HERE for U.S. State Department passport help. http://travel.state.gov/passport
If Yes to
Provide the issue date of passport.
Date (Estimated)
Provide the expiration date of passport.
Date (Estimated)
“passport”
Provide the name in which passport was first issued.
Last
First name:
Middle name:
Suffix
name:

Section 9 – Citizenship
Select the box that reflects your current citizenship status and click Save.
Provide your current citizenship status:
□ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. □ I am a naturalized U.S. citizen. □ I am a derived U.S. citizen. □ I
am not a U.S. citizen.
You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide type of documentation of U.S. citizen born abroad.
Explanation
(FS) 240, DS 1350, FS 545, Other (Provide explanation)
Provide document number for U.S. citizen born abroad:
Document Number (Free Text)
Branch
Provide the date the document was issued.
Date __-__-____ Estimated □
Provide the place of issuance.
City
State
Country
Foreign Born
Last name:
First
Middle
Suffix
to U.S. Parents Provide the name in which document was issued.
name:
name:
in a Foreign
Country
Provide your Certificate of Citizenship certificate number.
Certificate Number (Free Text)
Provide the place of issuance.
Street City
State Zip Code Court
Provide the date the certificate was issued.
Date __-__-____ (Estimated) Estimated □
Provide the name in which the certificate was issued.
Last name:
First
Middle
Suffix
name:
name:
Were you born on a U.S. military installation?
YES NO

Draft version 7 (December 2017)
You answered that you were born on a U.S. military installation.
Provide the name of the base.
Name (Free Text)
You answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S.
Date __-__-____ Estimated □
Provide the location of entry into the U.S.
City
State
Provide country(ies) of prior citizenship.
Country (Allows for Multiples)
Do/did you have a U.S. alien registration number?
YES NO
Branch If Yes
Provide your U.S. alien registration number on
Alien Registration Number (Free Text)
Certificate of Naturalization-utilize USCIS,
CIS, or INS registration number, I-551, I-766.
Provide your Certificate of Naturalization certificate number (N550 or N570). Certificate of Naturalization Certificate Number (Free
Text)
Provide the name of the court that issued the Certificate of Naturalization
Court (Free Text)
where was issued.
Street
City
State
Zip
Provide the address location of the court that issued the Certificate of
Court (Free Text)
Naturalization. where naturalization certificate was issued.
Provide the date the Certificate of Naturalization citizenship certificate was
Date __ -__-____ Estimated □
issued.
Street
City
State
Zip
Provide the name in which the Certificate of Naturalization certificate was
Last name:
First
Middle
Suffix
issued.
name:
name:
Provide the basis of naturalization. - Based on my own individual naturalization application,
Explanation
- Other (Provide explanation)
You answered that you are a derived U.S. citizen.
Provide your alien registration number (on Certificate of Citizenship — utilize USCIS, CIS or INS registration number)
Alien
Registration Number (Free Text)
Provide your Permanent Resident Card number (I-551)
Permanent Resident Card number (I-551) (Free Text)
Provide your Certificate of Citizenship number (N560 or N561)
Certificate of Citizenship number (N560 or N561) (Free Text)
Provide the name in which the document was issued.
Last name:
First name:
Middle name:
Suffix:
Provide the date document was issued Date __-__-___ Estimated __
Provide the basis of derived citizenship. -By operation of law through my U.S. citizen parent .-Other (Provide explanation)
Explanation
Not a U.S. Citizen
Provide your residence status.
Status (Free Text)
Provide your date of entry into the
Date __ -__-____ Estimated □
U.S.
Provide your country (ies) of citizenship. Allow multiple
Provide your place of entry in the U.S. City (Free Text) State
Provide your alien registration number. (I-151, I-766)
Registration Number (Free Text)
Provide document expiration date (I-766 ONLY).
Date__-__-____ Estimated □
Provide type of document issued. (I-94, U.S. Visa-red foil
I-94, U.S. Visa (red foil number), I-20, DS-2019,
Explanation
number, I-20, DS-2019, etc.)
Other (Provide explanation)
Provide document number:
Document Number (Free Text)
Provide the name in which the document was issued.
Last name:
First name:
Middle
Suffix
name:
Provide the date document was issued.
Date_-__-____
Provide document expiration date.
Date_-__-____
Estimated □
Estimated □
Branch If Yes

Branch
Citizenship
Naturalized
U.S. Citizen

Branch
Citizenship
Derived

Branch
Citizenship
Not a U.S.
citizen

Section 10 – Dual/Multiple Citizenship
Do you now or have you EVER held dual/multiple citizenships?
YES NO
You answered “Yes” to having EVER held dual/multiple citizenship
Provide country of citizenship
During what period of time did you hold citizenship with this country?
Provide the date range that you held this citizenship; beginning with the date it was
From Date
To Date (Estimated/Present)
Branch
acquired through its termination or “Present,” whichever is appropriate.
(Estimated)
How did you acquire this non-U.S. citizenship you now have or previously had?
How (Free Text)
Dual/Multiple
Citizenship
(Multiple
Entries
Allowed)

Do you currently hold citizenship with this country?
Branch
If Present/Current
Provide explanation:
Summary of dual/multiple citizenships you have listed: Allow multiple
Select Country Value
Dates of Citizenship
Do you have an additional citizenship to provide?
YES (Yes adds another entry)

YES

NO

Actions
NO (Required to validate)

Section 11 – Where You Have Lived
List the places where you have lived beginning with your present residence and working back 5 years. Residences for the entire period must be accounted
for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you
were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list
residence before your 18th birthday unless to provide a minimum of 2 years residence history.
You are not required to list temporary military duty locations of less than 90 days that did not serve as your permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew
you for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for periods of residence.
Enter residence information. (Multiple Entries Allowed)

Draft version 7 (December 2017)
Provide dates of residence.

From Date (Estimated )

To Date
(Estimated /Present)
Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation)
Explanation (Free Text)
Provide the street address.
Street address and City
Provide the country if outside the United States; otherwise provide
State
Zip Code
Country
State and Zip Code
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country
Branch
Physical
location or home port/fleet headquarter. Provide physical location data:
Location
Street Address/Unit/Duty Location:
City or Post Name
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the United States.
Branch
APO/FPO
Do/did you have an APO/FPO address while at this location?
Yes
No
Address
Branch You have indicated that you have or had and APO/FPO while at this location.
Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code Zip Code
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
Last
First
Middle
Suffix Provide date of last contact:
Date __-__-____ Estimated □
Provide the full name:
name: name: name:
Provide your relationship to this person (check all that apply)
□ Neighbor □ Friend □ Landlord □ Business associate
□ Other (Provide explanation) Explanation (Free Text)
Provide the following contact information for this person :
Provide evening phone number for this person: Number/Exte Provide daytime phone number for this person: Number/Extension
nsion
Time Day Night
Time Day
Both
Night Both
__Check box if
__Check box
International or
if
DSN phone number
International
_I don’t
Branch
or DSN
know
phone
Person Who
number
Knew you
_I don’t
know
(if address
Provide cell/mobile phone number for this person:
Number/Extension Time Day Night Both
dates within
__Check box if International or DSN phone number
last 3 years)
_I don’t know
Provide e-mail address for this person:
Email (Free Text) _I don’t know
Provide street address for this person (including apartment
Street address
City
number).
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and
Branch
country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name
Location
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the U.S.
Branch
APO/FPO
Does the person who knew you have an APO/FPO address?
YES NO
Address
Branch If Yes Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code
Zip Code
Do you have an additional residence to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 12 – Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed)
Have you attended any schools in the last 5 years?
YES NO
Have you received a degree or diploma more than 5 years ago?
YES NO
Provide the dates of attendance.
From Date (Estimated)
To Date (Estimated/Present)
Select the most appropriate box to describe your school. □ High School □ College/University/Military College
□ Vocational/Technical/Trade School
□ Correspondence/Distance/Extension/Online School
Provide the name of the school:
Name (Free Text)
Provide the street address of the school. For correspondence/distance/
Street address
City
extension/online schools, provide the address where the records are maintained.
For assistance determining the school address, refer to
http://ope.ed.gov/accreditation/search.aspx
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
Branch
Branch
provide State and Zip Code
If Yes to
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list
If Yes to
Attending
people for education periods completed more than 3 years ago. For correspondence/distance/extension/ online schools, list
Receiving
Schools
someone who knew you while you received this education
Degree
Provide the name of person who knows/knew you at school: □ I don’t know
Last
First
Initial Only □
name:
name:
No First Name □
Provide current address for this person (including apartment number).
Street
City
Provide Country if outside the United States; otherwise, provide State and Zip
State
Zip Code Country
Code
Provide telephone number for this person.
Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number

Draft version 7 (December 2017)
Provide email address for this person: □ I don’t know
Email (Free Text)
Did you receive a degree/diploma?
YES NO
Provide type of degrees(s)/diploma(s) received and date(s) awarded:
Degree/diploma
• High School Diploma
Other degree/diploma
Branch
• Associate’s • Bachelor’s • Master’s • Doctorate
If Yes to
Other Degree (Free Text)
• Professional Degree (e.g. MD, DVM, JD) • Other
Receiving Degree
Month / Year
Date __-__-____
Estimated □
Do you have additional education to enter (include education within the last 5
YES (Yes adds
NO (Required to
years, as well as degrees or diplomas more than 5 years ago)?
another entry)
validate)

Section 13a – Employment Activities – Employment & Unemployment Record
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 5 years. The entire
period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of
military duty station. Provide separate entries for employment activities with the same employer but having different physical
addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.
(Multiple Entries Allowed)
Select your employment activity: □ Active military duty station □ National Guard/Reserve □ USPHS Commissioned Corps
□ Other Federal employment
□ State Government (Non-Federal employment)
□ Self-employment □ Unemployment
□ Federal Contractor
□ Non-government employment (excluding self-employment)
□ Other (Provide explanation)
Other Type Explanation (Free Text)
Provide dates of employment.
From Date (Estimated)
To Date (Estimated/Present)
Active Duty, National Guard/Reserve, or USPHS Commissioned Corps
Select the employment status for this position: □ Full-time □ Part-time
Provide your assigned duty
Duty station (Free Text)
Provide your most recent
Rank/position (Free Text)
station during this period.
rank/position title.
Provide address of duty station.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code.
Telephone number
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
unit, and country location or home port/fleet headquarter.
Provide physical location data:
Branch
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip
Country
Branch
Code
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
If Employment
address while at this location?
APO/FPO
Type is Active
Address
Branch If Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Duty, National
Guard/Reserve,
Provide the name of your supervisor.
Supervisor name (Free Text)
or USPHS
Provide the rank/position title of your supervisor.
Supervisor rank/position (Free Text)
Commissioned
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Corps
Provide the physical work location of your supervisor.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide supervisor telephone number
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address,
base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your
Branch
supervisor:
Physical
Location
Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other
Provide most recent position title.
Position (Free Text)
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employer
Employer name (Free Text)
Provide the address of employer
Street address
City
Branch
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
If Employment
Provide telephone number
Number/Extension Time Day Night
Type is Other
Both
Federal
__Check box if International or DSN
employment,
phone number
State
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than
Government,
one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of
Federal
time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and
Contractor, Nonsupervisors for the two previous periods of employment as entries below). Not Applicable □ (Multiple Entries Allowed)
government
Dates of employment
From Date (Estimated)
To Date (Estimated/Present)
employment, or
Position title
Position (Free Text)
Supervisor
Supervisor (Free Text)
Other
Is/was your physical work address different than your employer’s address?
YES NO
Provide the work address where you are/were physically located.
Street Address
City
Branch
Provide Country if outside the United States; otherwise
State
Zip Code
Country
Physical
provide State and Zip Code
Location
Provide the telephone number for this supervisor.
Number/Extension Time Day Night Both

Draft version 7 (December 2017)

Branch
If Employment
Type is SelfEmployment

Branch
If Employment
Type is
Unemployment

__Check box if International or DSN phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Provide the name of your supervisor.
Supervisor name (Free Text)
Provide the position title of your supervisor.
Supervisor position (Free Text)
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Provide the physical work location of your supervisor.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide the telephone number for this supervisor.
Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address,
base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your
Branch
supervisor:
Physical
Location
Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Self-Employment
Provide most recent position title.
Position (Free Text)
Select the employment status for this position:
□ Full-time □ Part-time
Provide the name of your employment
Employment name (Free Text)
Provide the address of employment
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide telephone number
Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
Is your physical work address different than your employment address?
YES NO
Provide the work address where you are/were physically
Street address
City
located.
Provide Country if outside the United States; otherwise, provide State and Zip State
Zip
Country
Branch
Code
Code
Physical
Provide telephone number
Number/Extension Time Day Night
Location
Both
__Check box if International or DSN
phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Provide the name of someone that can verify your self-employment.
Last
First
Provide the address of this verifier.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide the telephone number for this person
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address for your self-employment verifier; provide physical location data with either
Branch
street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
Verifier
data for this person
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code Country
You have indicated an address outside of the United States. Does your self employment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Unemployment
Provide the name of someone who can verify your unemployment activities and means of support
Last
First name:
name:
Provide the address of this verifier.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide the telephone number for this person
Number/Extension Time Day Night Both _Check box if

Draft version 7 (December 2017)
International or DSN phone number
You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with either
Branch
street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
Verifier
data for this person:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code Country
You have indicated an address outside of the United States. Does your unemployment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Provide the reason for leaving the employment activity.
Reason (Free Text)
For this employment have any of the following happened to you in the last five (5) years?
YES NO
• Fired • Quit after being told you would be fired • Left by mutual agreement because of specific problems
following charges or allegations of misconduct • Left by mutual agreement following notice of unsatisfactory
performance
Branch

Select the type of incident: • Fired • Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
Branch
• Left by mutual agreement following notice of unsatisfactory performance
Provide the reason for being fired.
Reason (Free Text)
Branch
If Fired, Quit,
If Fired
Provide the date you were fired.
Date (Estimated)
Left by Mutual
Provide the reason for quitting.
Reason (Free Text)
Branch
Agreement, or
Provide the date you quit after being told you would be
Date (Estimated)
If Quit
Left After
fired.
Unsatisfactory
Provide the charges or allegations of misconduct.
Charges (Free Text)
Performance
Branch
Provide the date you left following charges or allegations
Date (Estimated)
If Left after Charges
of misconduct.
(Multiple
Provide the reason(s) for unsatisfactory performance.
Reason (Free Text)
Branch
Entries
If Left Unsatisfactory Provide the date you left by mutual agreement following a Date (Estimated)
Allowed)
performance
notice of unsatisfactory performance.
In the last five (5) years do you have another reason for leaving to
YES (Yes adds
NO (Required to
report for this employment?
another entry)
validate)
For this employment, in the last five (5) years have you received a written warning, been officially
YES NO
reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?
Officially reprimanded, suspended, or disciplined for misconduct.
Branch
If Disciplined,
Provide the month and year you were warned, reprimanded, suspended or
Date/ Estimated □
Warned,
disciplined.
Reprimanded, or
Provide the reason(s) for being warned, reprimanded, suspended or disciplined
Reason (Free Text)
Suspended
Do you have another instance of discipline or a warning to
YES (Yes adds
NO (Required to
(Multiple Entries
provide?
another entry)
validate)
Allowed)
Do you have an additional employment activity to enter?
YES (Yes adds another entry)
NO (Required to validate)
If Employment
Type is Active
Duty, National
Guard/Reserve,
USPHS
Commissioned
Corps, Other
Federal
employment,
State
Government,
Federal
Contractor, Nongovernment
employment,
SelfEmployment,
Unemployment,
or Other

Section 13b – Employment Activities – Former Federal Service
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
YES NO
Former Federal Service Detail
Provide dates of federal civilian employment.
From Date (Estimated)
To Date (Est/Present)
Branch
Provide the name of the federal agency for which you are/were employed.
Name
Provide your position title.
Position title (Free Text)
If Yes to Former
Provide the location of the agency
Street address and City
City
Federal Service
Provide Country if outside the
State
Zip Code
Country
United States; otherwise, provide
(Multiple Entries
State and Zip Code
Allowed)
Do you have additional former federal civilian employment, excluding military
YES (Yes adds
NO (Required to
service, NOT indicated previously, to report?
another entry)
validate)

Section 13b – Employment Record
Have any of the following happened to you in the last five (5) years at employment activities that you have not previously listed? (If Yes, you will be
required to add an additional employment in Section 13a)
• Fired from a job?
• Quit a job after being told you would be fired?
• Have you left a job by mutual agreement following charges or allegations of misconduct?
• Left a job by mutual agreement following notice of unsatisfactory performance?
• Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as violation of a security policy?
YES NO

Section 14 – Selective Service Record
Are you a male born Were you born a male after December 31, 1959?
YES
NO
Selective Service Registration
Have you registered with the Selective Service System (SSS)?
I don’t know
YES
NO
The Selective Service website, www.sss.gov, can help provide the registration number for persons who have
Branch
Branch
registered. Note: Selective Service Number is not your Social Security Number
If Yes
Provide registration number:
Registration number (Free Text)
If Yes to Born
You responded 'No' to having registered with the Selective Service System (SSS)
Branch
Male After
If No
Provide explanation
Explanation (Free Text)
12/31/1959
You responded 'I don't know' to having registered with the Selective Service System (SSS)
Branch
If I Don’t Know
Provide explanation
Explanation (Free Text)

Section 15 – Military History

Draft version 7 (December 2017)
Have you EVER served in the U.S. Military?
YES NO
You responded ‘Yes’ to having served in the U.S. Military:
Provide the branch of service you served in:
State of service, if National
Officer or enlisted: Provide your service number
□ Army □ Army National Guard
Guard
□ Not Applicable
(Free Text)
□ Navy □ Air Force □ Air National Guard
□ Officer
Provide your status
□ Marine Corps □ Coast Guard
□ Enlisted
□ Active Duty □ Active Reserve
Number (Free Text)
□ Inactive Reserve
Provide your dates of service
From Date (Estimated)
To Date (Estimated/Present)
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES NO
You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves
or National Guard.
Branch
Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable Conditions □
General □ Bad Conduct □ Other (provide type)
If Yes to
Discharged
Provide other discharge type:
Discharge explanation (Free Text)
Branch
Provide the date of discharge listed above
Date (Estimated)
Branch If Discharge Not Honorable
Provide the reason(s) for the discharge.
Reason(s) (Free Text)
If Yes to
Serving in
Do you have additional military service to report?
YES (Yes adds
NO (Required to
the U.S.
another entry)
validate)
Military
In the last 5 years, have you been subject to court martial or other disciplinary procedure
YES
NO
under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast,
(Multiple
Article 135 Court of Inquiry, etc?
Entries
You responded ‘Yes’ to having been subject to court martial or other disciplinary procedure under the Uniform Code of
Allowed)
Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc in the last 5 years.
Provide the date of the court martial or other disciplinary procedure.
Date (Estimated)
Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you
Description (Free
were charged.
Text)
Branch
Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast,
Name
If Yes to
Article 135 Court of Inquiry, etc.
(Free Text)
Military
Provide the description of the military court or other authority in which you were charged (title of
Description
Discipline
court or convening authority, address, to include city and state or country if overseas).
(Free Text)
Provide the description of the final outcome of the disciplinary procedure, such as found guilty,
Description
found not guilty, fine, reduction in rank, imprisonment, etc.
(Free Text)
In the last 5 years do you have an additional
YES (Yes adds another entry)
NO (Required to validate)
instance of military discipline to report?
Do you have additional military service to report?
YES (Yes adds another entry)
NO (Required to validate)
Have you EVER served as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces,
YES NO
militia, other defense force, or government agency?
You responded ‘Yes’ to having EVER served as a civilian or military member in a foreign country’s military, intelligence, diplomatic,
security forces, militia, other defense force, or government agency.
Branch
During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc.), Specify
□ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government Agency,
If Yes to
Specify
Serving in a Provide the name of the foreign organization.
Name (Free Text)
Foreign
Provide your period of service
From Date (Estimated)
To Date (Estimated/Present)
Military
Provide the name of the country
Provide your highest position/rank
Position held (Free Text)
held
(Multiple
Provide the division/department/office in which you served.
Division (Free Text)
Entries
Provide a description of the circumstances of your association with this organization.
Description (Free Text)
Allowed)
Provide a description of the reason for leaving this service.
Description (Free Text)
Do you have an additional foreign military service to report?
YES (Yes adds
NO (Required to
another entry)
validate)

Section 16 – People Who Know You Well
Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc.,
who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association with you covers at least
the last five (5) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form. (Multiple Entries Allowed)
Provide dates known
From Date
To Date (Estimated/Present)
Provide full name
Last
First
Middle
Suffix
(Estimated)
Provide rank/title
Rank/title (Free Text) Provide relationship to you: (Check all that apply) □ Neighbor □ Friend
Explanation
□ Not applicable
□ Work associate □ Schoolmate □ Other (Provide explanation)
(Free Text)
Provide phone number for this person.
□ I don’t know
Telephone/Extension
Time Day Night Both
_Check box if
International or DSN
phone number
Provide mobile/cell phone number for this person. □ I don’t know
Telephone/Extension
Time Day Night Both
_Check box if
International or DSN
phone number
Provide e-mail address for this person.
□ I don’t know
Email (Free Text)
Provide home or work address for this person.
Street address
City
Provide Country if outside the United States; otherwise, provide State and Zip Code.
State
Zip Code
Country
Do you have an additional person who knows you well to list?
YES (Yes adds another entry)
NO (Required to validate)

Draft version 7 (December 2017)

Section 16 – Police Record
For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or
the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an
expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad. Omit
(1) traffic fines of $300 or less, (2) any violation of law committed before your 16 th birthday, (3) any violation of law committed before your 18 th birthday if
finally decided in juvenile court or under a Youth Offender law, (4)any conviction set aside under the Youth Corrections Act or similar state law, and (5)
any conviction for which the record was expunged under Federal or state law.
Have any of the following happened? (If yes, you will be asked to provide details for each offense that pertains to the actions that are identified below.)
• In the last five (5) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do not check if all
the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs.)
• In the last five (5) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
• In the last 7 five (5) years have you been charged with, convicted of, or been imprisoned sentenced for a crime in any court? (Include all qualifying
charges, convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
• In the last 7 five (5) years have you been or are you currently on probation or parole?
• Are you currently under any charges for any violation of the law on trial or awaiting a trial on criminal charges?
YES NO
Provide the date of offense.

Date (Estimated)

Provide a description of the
specific nature of the offense.

Description (Free Text)

Provide the location where the offense occurred.
Street address and city
State and Zip Code or Country
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police
YES NO
officer, sheriff, marshal or any other type of law enforcement official?
Arresting/citing/summoning agency
Branch
If Yes to Being
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Name (free Text)
Arrested/Cited/
Provide the location of the law
Street address and city
State and Zip Code or Country
Summoned
enforcement agency.
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court
YES NO
in a criminal proceeding against you?
Branch - If No
You responded ‘No’ to “As a result of this offense were you charged, convicted, currently awaiting trial, and/or
to Charged or
ordered to appear in court in a criminal proceeding against you?”
Convicted
Provide Explanation
Explanation (Free Text)
Court information
Provide the name of the court.
Name of court (Free Text)
Provide the location of the court.
Street address and city
State and Zip Code or Country
Branch
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found
guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded guilty to a lesser
If Yes to the
offense, list separately both the original charge and the lesser offense.
Above
Felony/Misdemeanor
Felony, Misdemeanor, Other
Charge
Charge (Free Text)
Happening
Outcome
Outcome (Free Text)
Date (Month/Year)
Date
Branch
(Est.)
(Multiple
Were you sentenced as a result of this offense?
YES NO
If Yes to
Entries
Conviction detail
Charged or
Allowed)
Provide a description of the sentence.
Branch
Convicted
If the conviction resulted in imprisonment, provide the dates
From Date (Estimated)
If Yes to
that you actually were incarcerated. (Not Applicable □ )
Being
To Date (Estimated/Present)
Sentenced
If conviction resulted in probation or parole, provide the
From Date (Estimated)
dates of probation or parole. (Not Applicable □ )
To Date (Estimated/Present)
Trial detail
Branch
If No to
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal
YES NO
Being
charges for this offense?
Sentenced
Provide Explanation
Explanation (Free Text)
Do you have any other offenses where any of the following has happened to you?
YES
NO
• In the last five (5) years have you been issued a summons, citation, or ticket to appear in
(Yes adds
(Required to validate)
court in a criminal proceeding against you? (Do not include citations involving traffic
another entry)
infractions where the fine was less than $300 and did not include alcohol or drugs)
• In the last five (5) years have you been arrested by any police officer, sheriff, marshal or
any other type of law enforcement official?
• In the last five (5) years have you been charged with, convicted of, or sentenced for a crime
in any court? (Include all qualifying charges, convictions, or sentences in a Federal, state,
local, military, or non-U.S. court even if previously listed on this form.)
• In the last five (5) years have you been or are you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
Is there currently a domestic violence protective order or restraining order issued against you?
YES NO
You responded ‘Yes’ to currently having a domestic violence protective order or restraining order issued against you.
Branch
If Yes to
Provide explanation:
Explanation (Free Text)
Domestic
Provide the date the order was issued.
Date (Estimated)
Violence
Provide the name of the court or agency that issued the order.
Name of court (Free Text)
(Multiple
Provide
the
location
of
the
court
or
agency
that
issued
the
order.
Street address and city
State and Zip Code or Country
Entries
Do you have another domestic violence protective order or
YES
NO
Allowed)
restraining order currently issued against you to report?
(Yes adds another entry)
(Required to validate)

Section 17 – Illegal Use of Drugs and Drug Activity
We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as

Draft version 7 (December 2017)
evidence against you in a subsequent criminal proceeding. This particular section applies whether or not you are currently employed by the Federal
government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity not in accordance
with Federal laws, even if permissible under state laws.
In the last year have you illegally used any drugs or controlled substances? Use of a drug or controlled substance includes injecting, YES NO
snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.
You answered ‘Yes’ to in the year having illegally used a drug or controlled substance.
Branch
Provide the type of drug or controlled substance.
Explanation if other (Free Text)
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
If Yes to
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Illegally Using
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Drugs or
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Controlled
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Substances
Provide an estimate of the
Date (Estimated)
Provide an estimate of the month Date (Estimated)
month and year of first use.
and year of most recent use.
(Multiple
Provide nature of use, frequency, and number of times used.
Nature of use (Free Text)
Entries
Do
you
have
an
additional
instance(s)
of
illegal
use
of
a
drug
or
controlled
YES
NO
Allowed)
substance to enter?
(Yes adds another entry)
(Required to validate)
In the last year, have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping,
YES NO
receiving, handling or sale of any drug or controlled substance?
You answered ‘Yes’ to in the last year having been involved in the illegal purchase, manufacture, cultivation, trafficking, production,
transfer, shipping, receiving, handling or sale of a drug or controlled substance.
Provide the type of drug or controlled substance.
If other explanation (Free Text)
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Branch
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
If Yes to
Provide an estimate of the month Date
Provide an estimate of the month and
Date (Estimated)
Illegal Drug
and year of first involvement.
(Estimated)
year of most recent involvement.
Activity
Provide nature of and frequency of activity.
Nature of activity (Free Text)
Provide the reason(s) why you engaged in the activity.
Reason(s) (Free Text)
(Multiple
Do you have an additional instance(s) of having been involved in the illegal purchase,
YES
NO
Entries
manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale (Yes adds
(Required to
Allowed)
of a drug or controlled substance to enter?
another entry)
validate)
In the last year have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the drugs were
YES NO
prescribed for you or someone else?
You responded ‘Yes’ to in the last year having intentionally engaged in the misuse of prescription drugs, regardless of whether the drugs
Branch
If Yes to
were prescribed for you or someone else.
Misuse of
Provide the name of the prescription drug that you misused.
Drug names (Free Text)
Prescription
Provide the dates of involvement in the above.
From Date (Estimated)
To Date (Estimated/Present)
Drugs
Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Reasons (Free Text)
Do you have an additional instance(s) of intentionally engaging in the misuse
YES
NO
(Multiple
of prescription drugs in the last year to enter?
(Yes adds another entry) (Required to validate)
Entries
Allowed)
In the last year have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or
YES NO
controlled substances?
You responded ‘Yes’ to having in the last year, been ordered, advised, or asked to seek counseling or treatment as a result of your illegal
Branch
use of drugs or controlled substances
If Yes to
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or
Being Ordered
controlled substances? (Check all that apply)
Treatment for
□ An employer, military commander, or employee assistance program
□ A medical professional
the Misuse of
□ A mental health professional
□ A court official / judge
Drugs
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.
Provide explanation
Explanation (Free Text)
Did you take action to receive counseling or treatment?
YES NO
(Multiple
Branch If No
You have indicated that you did not receive treatment. Provide explanation.
Explanation (Free Text)
Entries
to Action Taken
Allowed)
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
Branch
If Yes to Action □ Inhalants (Such as toluene, amyl nitrate, etc.)
Taken
□ Other (Provide explanation):
Explanation (Free Text)
Provide the name of the treatment
Name (Free Text)
provider. (Last name, First name)
Provide the address for this treatment provider. Street address and city
State and Zip Code or Country
Provide a telephone number for the treatment provider.
Number/Ext. Extension Time Day
Night Both _Check box if
International
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)

Draft version 7 (December 2017)
Did you successfully complete the treatment?
YES NO
Branch If No
You have indicated that you did not successfully
Explanation (Free Text)
to Successful
complete the treatment. Provide explanation.
Treatment
Do you have another instance of having been ordered, advised, or asked to
YES
NO
seek drug or controlled substance counseling or treatment to enter?
(Yes adds another entry) (Required to validate)
In the last year have you voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance?
YES NO
Voluntary treatment detail
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Branch
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
If Yes to
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Voluntarily
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Seeking
Provide the name of the treatment provider. (Last name, First name)
Name (Free Text)
Treatment for
Provide the address for this treatment provider.
Street address and city
State and Zip Code or Country
the Misuse of
Provide a telephone number for the treatment provider.
Number/Ext ension Time Day Night
Drugs
Both _Check box if International
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
(Multiple
Did you successfully complete the treatment?
YES NO
Entries
Branch If No to
You have indicated that you did not you successfully complete the
Explanation (Free Text)
Allowed)
Successful Treatment treatment. Provide explanation.
Do you have another instance of voluntarily seeking counseling or
YES
NO
treatment as a result of your use of a drug or controlled substance in the
(Yes adds another entry)
(Required to validate)
last year?

Section 18 – Investigations and Clearance Record
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance
YES NO
eligibility/access?
You responded ‘Yes’ to the U.S. Government (or a foreign government) having investigated your background and/or having granted
you a security clearance eligibility/access.
Provide the investigating
□ U.S. Department of Defense
□ U.S. Department of State
agency:
□ U.S. Office of Personnel Management
□ Federal Bureau of Investigation
□ U.S. Department of Treasury (Provide name of bureau)
□ U.S. Department of Homeland Security
Explanation or name of
Branch
□ Foreign government (Provide name of government) □ I don’t know
government or bureau. (Free
If Yes to Having
□ Other (Provide explanation)
Text)
Ever Been
Date the investigation was completed.
□ I don’t know
Date (Estimated)
Investigated
Was a clearance eligibility/access granted? Yes
No
Name (Free Text)
If yes, provide the name of agency that issued the clearance eligibility/access if different from the
(Multiple Entries
investigating agency.
Allowed)
Provide the date clearance eligibility/access was granted. □ I don’t know
Date (Estimated)
Provide the level of clearance
□ None
□ Confidential
□ Secret
□ Top Secret
eligibility/access granted.
□ Sensitive Compartmented Information (SCI) □ Q
□L
□ I don’t know
□ Issued by foreign country
□ Other (Provide explanation)
Explanation (Free Text)
Do you have another investigation to enter?
YES (Yes adds another entry)
NO (Required to validate)
In the last five (5) years have you had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An
YES NO
administrative downgrade or administrative termination of a security clearance is not a revocation.)
You responded ‘Yes’ to having a security clearance eligibility/access authorization denied, suspended, or revoked within the last five
(5) years.
Branch
Provide the date security clearance eligibility/access authorization was denied, suspended or revoked.
Date (Estimated)
If Yes to Denied
Provide the name of the agency that took the action.
Name (Free Text)
(Multiple Entries
Provide an explanation of the circumstances of the denial, suspension or revocation action.
Explanation (Free Text)
Allowed)
Do you have another denied, revoked or suspended security
YES
NO
clearance eligibility/access authorization to enter?
(Yes adds another entry) (Required to validate)
In the last five (5) years have you been debarred from government employment?
YES
NO
You responded ‘Yes’ to in the last 5 years having been debarred from government employment.
Branch
Provide the name of the government agency taking debarment action.
Agency name
If Yes to
Debarment
Provide the date the debarment occurred.
Date (Estimated)
(Multiple Entries
Provide an explanation of the circumstances of the debarment
Circumstances (Free text)
Allowed)
Do you have another Government debarment to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 19 – Financial Record
In the last five (5) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?
YES
NO
You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Branch
Did you fail to file, pay as required, or both? □ File □ Pay □ Both
Provide the year you failed to file or pay your Federal, state or other taxes.
Est.
If Yes to
Provide the reason(s) for your failure to file or pay required taxes.
Reasons (Free Text)
Failing to
Provide the Federal, state or other agency to which you failed to file or pay taxes.
Agency (Free Text)
File/Pay Taxes
Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.).
Tax Type (Free Text)
Provide
the
amount
(in
U.S.
dollars)
of
the
taxes.
□
Estimated
Amount (Free Text)
(Multiple
Provide date satisfied. □ Not applicable
Date (Estimated)
Entries
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
Allowed)
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.

Draft version 7 (December 2017)
Are there any other instances in the last five (5) years where you failed to
YES
NO
file or pay Federal, state or other taxes when required by law or ordinance?
(Yes adds another entry) (Required to validate)
Other than previously listed, has the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the
items identified below).
• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).
YES

NO

Provide the associated loan / account number(s) involved
Loan / account number (Free Text)
Identify/describe the type of property involved (if any).
Property type (Free Text)
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated
Amount (Free Text)
Provide the reason(s) for the financial issue.
Reasons (Free Text)
Provide the current status of the financial issue.
Status (Free Text)
Provide the date the financial issue began.
Date (Estimated)
Provide date the financial issue was resolved. □ Not resolved
Date (Estimated)
Provide the name of the court involved.
Court name (Free Text)
Provide the address of the court involved.
Street address and City
State and Zip Code or Country
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
frequency and amount of payments, etc.). If you have not taken any provide explanation.
Other than previously listed, are there any other instances of the following occurrence?
• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for
which you are a cosigner or guarantor).

YES (Yes adds another entry)

NO (Required to validate)

1E a

Section 20 – Association Record
The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an
adverse employment or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are
dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.
Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the
YES NO
organization’s dedication to that end, or with the specific intent to further such activities?
You responded ‘Yes’ to being or EVER having been a member of an organization dedicated to terrorism, either with an awareness of
Branch
the organization’s dedication to that end, or with the specific intent to further such activities.
Provide the full name of the organization.
Organization name (Free Text)
If Yes to Being a
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Member of a
Provide the dates of your involvement with the organization.
From Date (Estimated)
To Date (Estimated/Present)
Terrorist
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Organization
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
Provide
a
description
of
the
nature
of
and
reasons
for
your
involvement
with
the
organization.
Involvement (Free Text)
(Multiple Entries
Do you have any other instances of being a member of an organization dedicated to
YES
NO
Allowed)
terrorism, either with an awareness of the organization’s dedication to that end, or with the
(Yes adds
(Required to
specific intent to further such activities to report?
another entry)
validate)
Have you EVER knowingly engaged in any acts of terrorism?
YES NO
Branch If Yes
You responded ‘Yes’ to EVER having knowingly engaged in any acts of terrorism.
Engaging in
Describe the nature and reasons for the activity.
Nature and reasons (Free Text)
Terrorism
Provide the dates for any such activities
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of knowingly engaging in acts of
YES
NO
Allowed)
terrorism to report?
(Yes adds another entry)
(Required to validate)
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?
YES
NO
You responded ‘Yes’ to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
Branch
force.
If Yes to
Provide the reason(s) for advocating acts of terrorism.
Reasons (Free Text)
Advocating
Provide the dates of advocating acts of terrorism
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of advocating acts of terrorism or activities
YES (Yes adds
NO (Required to
Allowed)
designed to overthrow the U.S. Government by force to report?
another entry)
validate)
Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States
YES NO
Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the
specific intent to further such activities?
You responded ‘Yes’ to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the
Branch
United States Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or
with the specific intent to further such activities.
If Yes to being
Provide the full name of the organization.
Organization name (Free Text)
Member of
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Organization
Provide the dates of your involvement with the organization
From Date (Estimated)
To Date (Estimated/Present)
Using Violence
to Overthrow the
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
U.S. Govt.
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
Provide a description of the nature of and reasons for your involvement with the organization.
Description (Free Text)
(Multiple Entries
Do you have any other instances of being a member of an organization dedicated to the use
YES
NO
Allowed)
of violence or force to overthrow the United States Government, which engaged in
(Yes adds
(Required to

Draft version 7 (December 2017)
activities to that end with an awareness of the organization’s dedication to that end or with
another entry)
validate)
the specific intent to further such activities to report?
Have you EVER been a member of an organization that advocates or practices commission of acts of force or violence to
YES NO
discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to
further such action?
You responded ‘Yes’ to being or EVER having been a member of an organization that advocates or practices commission of acts of
force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the
specific intent to further such action.
Provide the full name of the organization.
Organization Name (Free Text)
Branch
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
If Yes to Being a
Provide the dates of your involvement with the organization
From Date (Estimated)
To Date (Estimated/Present)
Member of
Organization
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Using Violence
Provide all contributions (in U.S. dollars) made to the organization, if any. □ No contributions
Contributions (Free Text)
made
(Multiple Entries
Provide a description of the nature of and reasons for your involvement with the organization.
Involvement (Free Text)
Allowed)
Do you have any other instances of being a member of an organization that advocates or
YES
NO
practices commission of acts of force or violence to discourage others from exercising
(Yes adds
(Required to validate)
their rights under the U.S. Constitution or any state of the United States with the specific
another entry)
intent to further such action to report?
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?
YES
NO
Branch If Yes to You responded ‘Yes’ to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Describe the nature and reasons for the activity.
Reasons (Free Text)
Activities to
Overthrow
Provide the dates of such activities.
From Date (Estimated)
To Date Estimated/Present)
(Multiple Entries
Do you have any other instances of having knowingly engaged in activities YES
NO
Allowed)
designed to overthrow the U.S. Government by force to report?
(Yes adds another entry) (Required to validate)
Have you EVER associated with anyone involved in activities to further terrorism?
YES
NO
Branch If Yes to
Terrorism Association Detail
Having
Provide Explanation
Explanation (Free Text)
Terrorism
Association
Additional Comments
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate,
and then sign and date the following certification and the attached release(s).

Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in
good faith. I have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this
form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or
falsifying information may have a negative effect on my employment prospects, or job status, or my removal and debarment from Federal
service.
Signature (Sign in ink)

Date (mm/dd/yyyy)

Draft version 7 (December 2017)
Standard Form 85
Revised December 2013
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OMB No. 3206-0261

QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation or reinvestigation to obtain any information relating to my activities,
conduct, and character from individuals, schools, residential management agents, employers, criminal justice
agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other
sources of information. This information may include, but is not limited to current and historic my academic,
residential, achievement, performance, attendance, disciplinary, employment history, criminal history record
information, financial, and credit information, and publicly available social media information. I authorize the
Federal agency conducting my investigation to disclose the record of my background investigation or ongoing
evaluation to the requesting agency for the purpose of making a determination of suitability or eligibility for a nonsensitive position and/or for physical or logical access to federal facilities and information systems.
I Understand that, for these purposes, publicly available social media information includes any electronic social
media information that has been published or broadcast for public consumption, is available on request to the public,
is accessible on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully
accessible to the public. I further understand that this authorization does not require me to provide passwords; log
into a private account; or take any action that would disclose non-publicly available social media information.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name,
Social Security Number, and date of birth with information in SSA records and provide the results of the match) to
the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my
investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the
other Federal agency requesting or conducting my investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and
other sources of information, a separate specific release may be needed, and I may be contacted for such releases at
a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau
of Investigation, the Department of Defense, the Department of Homeland Security, the Office of the Director of
National Intelligence, Department of State, and any other authorized Federal agency, to request criminal record
information about me from criminal justice agencies for the purpose of determining my suitability or eligibility for
appointment to, or retention in, a non-sensitive position, in accordance with 5 U.S.C. 9101 or my eligibility for
logical or physical access. I understand that I may request a copy of such records as may be available to me under
the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of any Federal agency
authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by
the Federal Government only for the purposes provided in this Standard Form 85, and that it may be disclosed by the
Government only as authorized by law.
I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and
analyses, which will be maintained in accordance with the Privacy Act.
Photocopies of this authorization with my signature are valid. This authorization is valid for two five (25) years from
the date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)
Other names used

Full name (Type or print legibly)
Date of birth

Date signed (mm/dd/yyyy)
Social Security Number

Draft version 7 (December 2017)
Current street address Apt. #

City (Country)

State

ZIP Code

Home Telephone number

Draft version 7 (December 2017)
Standard Form 85
Revised December 2013
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OMB No. 3206-0261

SF 85 QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS
UNITED STATES OF AMERICA
FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment
purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
Depending on circumstances within your background, the Federal government may require
information from one or more consumer reporting agencies in order to obtain information in
connection with a background investigation, reinvestigation, or ongoing evaluation (i.e.
continuous evaluation) for positions designated as low risk, non-sensitive, and for physical and
logical access. The information obtained may be disclosed to other Federal agencies for the
above purposes in fulfillment of official responsibilities to the extent that such disclosure is
permitted by law. Information from the consumer report will not be used in violation of any
applicable Federal or state equal employment opportunity law or regulation.
Authorization
I hereby authorize any investigator, special agent, or other duly accredited representative of the
authorized Federal agency conducting my initial background investigation, reinvestigation, or
ongoing evaluation (i.e. continuous evaluation) of my for positions designated as low risk, nonsensitive, and for physical and logical access to request, and any consumer reporting agency to
provide, such reports for the purposes described above.
Note: If you have a security freeze on your consumer or credit report file, we will not be able to
access the information necessary to complete your investigation, which can adversely affect your
eligibility for a non-sensitive position. To avoid such delays, you should expeditiously respond
to any request made to release the credit freeze for the purposes as described above.
Photocopies of this authorization with my signature are valid. This authorization shall remain in
effect so long as I occupy a non-sensitive position.
Print name

Social Security Number

Signature (Sign in ink)

Date (mm/dd/yyyy)


File Typeapplication/pdf
File TitleQuestionnaire for National Security Positions
AuthorLoss, Lisa M
File Modified2017-12-27
File Created2017-12-27

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