Form USM-271 Leased/Charter Flight Personnel Expedited Clearance Requ

OMB Number _________ (Exp. ____/____)
U.S. Department of Justice
United States Marshals Service

Leased/Charter Flight Personnel Expedited Clearance Request

1. Last Name:

2. First Name:

3. Middle Name (Full):

4. Other Names Used:

5. Social Security Number:

6. Date of Birth:

7. Place of Birth:

9. Gender (M or F):

8. Citizenship:

10. Race:

11. Height:

14. Home Address - Street:

12. Weight (lbs.):

15. City:

18. Driver's License #:

19. Issuing State:

13. Eye Color:

16. State:

17. ZIP Code:

20. Occupation (Pilot / Flight Attendant / Mechanic / Nurse / Other):

21. List all of the U.S. states you have lived in within the past 10 years (use state abbreviations):

22. Have you ever been arrested? 23. If yes, list charge/violation/disposition:
No

Yes

CERTIFICATION: I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge
and belief, and are made in good faith. I have read and understand the information on the second page of this form, and I authorize
the use and release of this information in accordance with the stated purpose.
24. Signature of Applicant

25. Printed Name

26. Date

TO BE COMPLETED BY THE USMS COMMUNICATONS CENTER
1. NCIC Check Completed By:
4. Wanted Person?

2. Date:

Yes

5. Criminal History?

No

Yes

3. Time:
No

6. Remarks:

TO BE COMPLETED BY THE USMS JUSTICE PRISONER AND ALIEN TRANSPORTATION SYSTEM (JPATS)
1. NCIC Check Received By:
4. Clearance Granted?

2. Date:
Yes

3. Time:

No

5. Remarks:

Reset Form

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Form USM-271
Rev. 7/2012

INSTRUCTIONS FOR LEASED/CHARTER PERSONNEL TO COMPLETE THIS FORM
1. Complete all fields. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or
"N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or
"EST."
2. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, USMS may modify the form
consistent with your intent.
3. You must use U.S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.
4. All telephone numbers must include area codes.
5. All dates provided on this form must be in Month/Day/Year (mm/dd/yy) or Month/Year (mm/yy) format. Use numbers (1-12) to indicate months. For example,
May 27, 1972 should be shown as 5/27/72.
6. Question 9 (nine) should be answered from the following available choices in NCIC: F-Female; M-Male; or U-Unknown
7. Question 10 (ten) should be answered from the following available choices in NCIC: I-American Indian or Alaskan Native; A-Asian or Pacific Islander;
B-Black; U-Unknown; W-White or White Hispanic
6. If you need additional space to complete this form, please use a separate blank sheet of paper.
PURPOSE OF THIS FORM
The U.S. Government conducts criminal checks to establish that applicants
or incumbents either employed by the Government or working for the
Government under contract are eligible for the job. The U.S. Marshals
Service will use this form to conduct a National Criminal Information Center
(NCIC) check for each temporary contractor (working on contract 6 months
or less and require physical access only) to determine eligibility to work on
U.S. Marshals Service contracts.
AUTHORITY TO REQUEST THIS INFORMATION
The U.S. Government is authorized to ask for this information under 5 CFR
731, Suitability Regulations. Your Social Security number is needed to
keep records accurate, because other people may have the same name
and birth date. Executive Order 9397 also asks Federal agencies to use
this number to help identify individuals in agency records.
THE BACKGROUND CHECK PROCESS
The U.S. Marshals Service inputs the information from this completed form
into the NCIC Database and conducts a pre-employment name check
through the National Crime Information Center (NCIC). The system will
produce a criminal history report, that is reviewed by designated U.S.
Marshals Service personnel. The designated U.S. Marshals Service
personnel will determine the eligibility of the temporary contractor based
upon the information provided by the check.

Act system of record notice published in the Federal Register at 73 FR
35690 on June 24, 2008. Disclosure of the information by you is voluntary.
Information may be transferred as a routine use to appropriate Federal,
state, local, or foreign agencies when relevant to civil, criminal or
regulatory investigation, prosecutions, or pursuant to a request by DHS or
such other agency is in connection with the hiring or retention of an
employee, the issuance of a license, grant, or other benefit. Information
also may be transferred as a routine use to a duly authorized official
engaged in an investigation or settlement of a grievance, complaint, or
appeal filed by an employee. Failure to provide information requested on
this form may result in the government’s inability to determine your
eligibility for the position applied for or occupied, and may affect your
prospects for employment or continued employment under a government
contract, or at a Federal facility, or with a government license.
PRIVACY ACT ROUTINE USES
1.
2.
3.
4.
5.

FINAL DETERMINATION ON YOUR ELIGIBILITY
Final determination on your eligibility for a position is the responsibility of
the U.S. Marshals Service. You may be provided the opportunity
personally to explain, refute, or clarify any information before a final
decision is made.

6.

7.

AUTHORIZATION AND RELEASE
I hereby authorize the U.S. Marshals Service and other authorized Federal
agencies to obtain any information required from the Federal government
and/or state agencies, including but not limited to, the Federal Bureau of
Investigation (FBI), the Defense Investigation Service (DIS), the U.S. Office
of Personnel Management (OPM), the U.S. Department of Homeland
Security (DHS), (if applicable). This authorization is valid for one year from
the date this form was signed.
I have been notified of any employer’s right to require a criminal history
records check as a condition of employment. I understand that I may
request a copy of such records as may be available to me under the law. I
understand that I have a right to challenge the accuracy and competencies
of any information contained in the report. I also understand that this
information will be treated as privileged and confidential information. Case
files are handled under the procedures for safeguarding records.
I release any individual, including records custodians, any component of
the U.S. Government or the individual State Criminal History Repository
supplying information, from all liability for damages that may result on
account of compliance, or any attempts to comply with this authorization.
This release is binding, now and in the future, on my heirs, assigns,
associates, and personal representative(s) of any nature. Copies of this
authorization that show my signature are as valid as the original release
signed by me.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
Solicitation of information contained herein is authorized by Executive
Order 10450 and may be used as a basis for eligibility determinations. The
USMS describes how your information will be maintained in the Privacy

8.
9.
10.
11.

To U.S. Marshals Service personnel when needed for official business,
including designated analysts and managers for official business;
To verify eligibility of an employee or contractor before granting access to
specific resources;
To disclose information to agency staff and administrative offices who may
restructure the data for management purposes;
In any legal proceeding, where pertinent, to which the US Marshals Service
is a party before a court or administrative body;
To authorized officials engaged in investigating or settling a grievance,
complaint, or appeal filed by an individual who is the subject of the record;
To a Federal, state, local, foreign, or tribal agency in connection with the
hiring or retention of an employee; the issuance of a security clearance; the
reporting of an investigation; the letting of a contract; or the issuance of a
grant, license, or other benefit to the extent that the information is relevant
and necessary to a decision;
To the Office of Personnel Management (OPM), the Office of Management
and Budget (OMB), or the Government Accountability Office (GAO) when the
information is required for program evaluation purposes;
To a Member of Congress or staff on behalf of and at the request of the
individual who is the subject of the record;
To an expert, consultant, or contractor of the US Marshals Service in the
performance of a Federal duty to which the information is relevant;
To the National Archives and Records Administration (NARA) for records
management purposes;
To appropriate agencies, entities, and persons when (1) the Agency suspects
or has confirmed that the security or confidentiality of information in the system
of records has been compromised; (2) the Agency has determined that as a
result of the suspected or confirmed compromise there is a risk of harm to
economic or property interests, identity theft or fraud, or harm to the security or
integrity of this system or other systems or programs (whether maintained by
the U.S. Marshals Service or another agency or entity) that rely upon the
compromised information; and (3) the disclosure made to such agencies,
entities, and persons is reasonably necessary to assist in connection with
GSA's efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm.

PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to
average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspects of this
collection of information, including suggestions for reducing this burden, to
JPATS, U.S. Marshals Service, 1251 NW Briarcliff Parkway, Suite 300,
Kansas City, MO 64116. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

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