Form 20-10276 VBA Contractor Background Investigation Request

OMB Control No. 2900-NEW
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/XXXXX

VBA CONTRACTOR BACKGROUND INVESTIGATION REQUEST

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on Page 2. Use this form to submit contractor
background investigation requests. If you have questions about this request form, we can be reached by telephone (202) 461-9422 or by email at
[email protected]. After completing the form, the Contracting Officer Representative (COR) will upload it to:
https://va-vet.lightning.force.com.
SECTION I: APPLICANT INFORMATION (Completed by Applicant)
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and
completely fill in each applicable check box to help expedite processing of the form.
1. APPLICANT'S LEGAL NAME (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER

3. COUNTRY OF BIRTH

5. DATE OF BIRTH (MM/DD/YYYY)

6. CITIZENSHIP

4. CITY AND STATE OF BIRTH

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

8. NAME AND ADDRESS OF ASSIGNED DUTY STATION (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

9. EMAIL ADDRESS (REQUIRED)

SECTION II: CONTRACT INFORMATION (Completed by Contracting Officer Representative (COR))
10. NAME OF CONTRACTOR'S COMPANY
11B. CONTRACT START DATE (MM/DD/YYYY) 11C. CONTRACT END DATE (MM/DD/YYYY)

11A. CONTRACT NUMBER
12. COMPANY/VENDOR POINT OF CONTACT (POC)
13. POC TELEPHONE NUMBER

14. POC EMAIL ADDRESS

SECTION III: CONTRACTING OFFICER REPRESENTATIVE INFORMATION (Completed by COR)
15. NAME OF CONTRACTING OFFICER REPRESENTATIVE (COR)
16. COR LOCATION (City and State)

17. COR EMAIL ADDRESS

18. COR BUSINES LINE/STAFF OFFICE/REGIONAL OFFICE

SECTION IV: SPONSOR INFORMATION
19. NAME OF SPONSOR CONTRACTING OFFICER REPRESENTATIVE (COR)
20. NAME AND ADDRESS OF FACILITY OR ASSIGNED DUTY STATION

21. TYPE OF PERSONNEL IDENTIFICATION VERIFICATION (PIV) REQUEST (Select one)

VA FORM
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20-10276

22. TYPE OF ACCESS (Select one)

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SECTION V: TYPE OF BACKGROUND CHECK
23. SELECT TYPE
23A. DATE INITIATED BACKGROUND
INVESTIGATION (MM/DD/YYYY)

23B. DATE SAC INITIATED

(MM/DD/YYYY)

23C. DATE ADJUDICATED BACKGROUND
INVESTIGATION (MM/DD/YYYY)

23D. DATE SAC ADJUDICATED

(MM/DD/YYYY)

SECTION VI: APPLICANT SELF CERTIFICATION OF CONTINUOUS SERVICE
24. Federal employment is defined as service in any branch of the United States military (Active, Guard, or Reserve), federal government civilian employment (any
federal government agency), or a contractor working for the federal government. I hereby certify my break in service from my last federal employment is indicated by the
block checked below.
I have NOT had a break in service. (Select one option)
My service was intra-agency (i.e., VA, VBA, VHA, NCA)
My service was inter-agency (other government agency, i.e., DOD, FBI, CIA, DOS, HHS, DHS, NSA, DOJ, NIH, etc.)
My break in service was less than 60 days.
My break in service was greater than 60 days, but less than two (2) years.
My break in service is greater than two (2) years OR I have never had federal employment as defined above.
26. DATE (MM/DD/YYYY)

25. SIGNATURE OF APPLICANT

SECTION VII: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
27. SIGNATURE (REQUIRED)

28. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a
material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.
PRIVACY ACT STATEMENT: VA is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (HSPD)-12, and
31 USC 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under HSPD-12 are used to verify the personal
identity of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department
identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contractors, and affiliates issued a
Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal
government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 USC Section 552(a)
and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)".
VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including civil or criminal
law enforcement, constituent congressional communications initiated at your request, litigation, or administrative proceedings in which the United States is a party
or has an interest, the administration of VA programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of
the requested information may result in VA being unable to process your request for a Personal Identity Verification Card, or denial of issuance of a Personal
Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to VA facilities or networks, which could have
an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perform your assigned duties
or responsibilities.
RESPONDENT BURDEN: This form is used to request information that is necessary for the validation and determinations of suitability and trustworthiness of
the applicant in order to to adjudicate the background investigation requirements so that the applicant can receive a personal identity verification (PIV) Card to
access VA systems. It should take you about 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a
collection of information unless a valid Office of Management and Budget (OMB) control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If
desired, you can contact Joylisa Jenkins at [email protected] to get information on where to send comments or suggestions about this form.

VA FORM 20-10276, XXXX

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