3206-NEW PVQ Part B

For Reference Only

Part B – Mandatory for All Positions Except Low Risk

Continuation of Section 04 - Additional Citizenships/Foreign Passports Questions

This section also asks for information regarding any foreign (non-U.S.) passports you currently hold or have previously held.

For the following questions the term "foreign" means non-U.S. (that is, outside of the 50 U.S. states, District of Columbia, and U.S. territories). Many non-U.S. countries issue "identity cards" which can be used for international travel. Some of these identity cards cannot be used for international travel and are issued for other reasons (for example, as identification, to claim benefits, to digitally sign documents, etc.). For this question, only list an identity card if it can be used for international travel, even if you have never used it for international travel. Consider the term "identity card" to include all identity documents, citizenship cards, registration documents, foreign visas, or other similar documents that can be used for international travel.

Have you ever had a foreign passport, identity card, or other similar document for international travel?		[] Yes	[] No
		[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer on Foreign Passport or Identity Card. Country of Origin.

What country issued this passport, identity card, or other similar document for international travel?

[ Dropdown ]

Do you have access to this document?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Foreign Passport or Identity Card with Access to Document.

What is the issue date of this document?

[ mm/dd/yyyy ]

[] Estimated

What is the expiration date of this document?

[ mm/dd/yyyy ]

[] Estimated

Where was this document issued?

City

[ Text ]

Country

[ Dropdown ]

What name is used on this document?

Last Name

[ Text ]

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

What is the document number?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Foreign Passport or Identity Card. Use of Foreign Passport or Identity Card.

Have you ever used this document for international travel?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Use of Foreign Passport or Identity Card. Used for Travel.

What country did you travel to?

[ Dropdown ]

When did you travel to this country?

From

[ mm/dd/yyyy ]

[] Estimated

To

[ mm/dd/yyyy ]

[] Estimated

[] Present

How long was this trip?

[ Dropdown ]

[3] Branch Auto Populate for Selection of “Other” on Length of Foreign Travel on Foreign Passport or Identity Card.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Purpose of Travel.

Why did you travel to this country?

[ Dropdown ]

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card for Selection of “Other” for Purpose of Travel.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Questioned by Foreign Entity.

While traveling to, from, or within this country, were you questioned, searched, or otherwise detained by customs, security officials, or any other entity? (This does not include those conducted as part of the normal customs’ process.)

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card for Affirmative Answer on Questioned by Other Entity.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Encounters with Police.

While traveling to, from, or within this country, did you have any encounters with the police?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card for Affirmative Answer on Police Interaction.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Foreign Government Encounters.

While traveling to, from, or within this country, did you have contact with any person who you know or suspect is involved or associated with a foreign military, intelligence service, diplomatic service, security service, militia, other defense force, or government agency?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Affirmative Answer Foreign Government Encounters.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Suspicious Activity.

While traveling to, from, or within this country, did you have any incidents that were a potential security concern or considered suspicious activity, such as someone following you?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Affirmative Answer Suspicious Activity.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Foreign Contact Interest.

While traveling to, from, or within this country, did you have contact with anyone who had personal knowledge of or undue interest in you or your work?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Affirmative Answer Foreign Contact Interest.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Request for Classified/Sensitive Information.

While traveling to or within this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive information?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Affirmative Answer Request for Classified/Sensitive Information Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Threatened, Coerced, Pressured.

While traveling to, from, or within this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official (such as from a foreign military, intelligence service, diplomatic service, security service, a militia, other defense force)?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card Affirmative Answer for Threatened, Coerced, Pressured. Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Additional Instance.

Do you have another instance in which you used this document for international travel to report?

[] Yes

[] No

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Intentions.

Do you intend to keep this document?

[] Yes

[] No

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card for Intent to Keep Document.

Do you intend to use this document for international travel?

[] Yes

[] No

[3] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card. Affirmative Answer to Intend to Use.

Please explain.

[ Text ]

[2] Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card for a Negative Answer to Intend to Keep.

Please explain.

[ Text ]

*** End Of Branch ***

Continuation of Section 07 - Employment

This section asks questions regarding any foreign service you have had, as applicable. If you have foreign service then we want to collect information regarding your work and any foreign nationals you keep in contact with from your time serving in that foreign government.

For this section:

• Foreign -- means non-U.S. -- that is, outside of the 50 U.S. states, District of Columbia, and U.S. territories.

• Foreign service -- is work performed for a non-U.S. government and its agencies. Examples of foreign agencies and disciplines include foreign embassies, consulates, military or armed forces, intelligence services, diplomatic services, and security services.

• Foreign national -- is any person who is not a citizen or national of the U.S.

Have you ever served in a foreign government?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Name.

Which foreign government discipline do you or did you serve in?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Selection of “Other” in Name of Foreign Government. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Additional Questions.

What country is or was your foreign service for?

[ Dropdown ]

What foreign agency do you or did you serve in? (Do not use acronyms.)

[ Text ]

Are you or were you a civilian or a military member?

[ Dropdown ]

What is the highest position or rank you held in this foreign agency?

[ Text ]

Which division, department, or office do you or did you serve in? (Do not use acronyms.)

[ Text ]

How did you become associated with this foreign agency?

[ Text ]

When did you serve in this foreign agency?

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month/Year)

[ mm/yyyy ]

[] Estimated

[] Present

[2] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Reason Service Ended.

Why did you leave this foreign agency?

[ Text ]

[1] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Further Contact.

Do you maintain contact with any foreign nationals from your time working at this foreign agency? ("maintain contact" includes ‘now and an intent to have contact in the future.)

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Service. Further Contact. Contact’s Information.

What is their name?

Last Name	[ Text ]
First Name	[ Text ]
Suffix	[ Dropdown ]	[] None
What is their job title and rank if applicable?	[ Text ]

When did you meet this individual?

[ mm/yyyy ]

[] Estimated

When was your last contact with this individual?

[ mm/yyyy ]

[] Estimated

How often do you have contact with this individual?

[ Dropdown ]

[3] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Contact Frequency Selection of “Other” from Dropdown Menu. Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government Further Contact Location.

Does this person live or work in the U.S.?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Contact Location in the U.S.

What is their address?

Street

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Contact Location Not in the U.S.

Where are they located?

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Contact Relationship. Another Instance of Contact with Foreign Service National.

What is your current relationship with this person?

[ Text ]

Do you have another foreign national with whom you maintain contact from your time working at this foreign agency to report?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Ever Served in Foreign Government. Another Instance or Service.

Do you have another period of foreign service to report?

[] Yes

[] No

*** End Of Branch ***

Continuation of Section 11 - Police Record

Continuation of Question 11.1.B This question asks for information regarding offenses where you received a document listing criminal charges and were requested to appear in criminal court. These documents are typically for offenses such as misdemeanors, felonies, or their equivalents. The written documents could include citations, summonses, tickets, complaints, arrest warrants, or indictments.

Were you charged with a felony more than five years ago?

[] Yes

[] No

Were you charged with a crime involving firearms or explosives more than five years ago?

[] Yes

[] No

Were you convicted of a crime involving domestic violence more than five years ago?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Date and Location of Incident
What is the date of the offense?	mm/dd/yyyy		[] Estimated
Did this offense occur in the U.S.?		[] Yes		[] No

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Incident Location in U.S.

Where did it occur?

City	[ Text ]
County or County Equivalent	[ Text ]
State or Territory	[ Dropdown ]
ZIP Code	[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Incident Location Not in the U.S.

Where did it occur?

City	[ Text ]
Country	[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Questions

Was domestic violence involved?

[] Yes

[] No

Were firearms involved?

[] Yes

[] No

Were explosives involved?

[] Yes

[] No

Were drugs involved?

[] Yes

[] No

Was alcohol involved?

[] Yes

[] No

What is the name of the law enforcement agency involved? (Do not use acronyms.)

[ Text ]

Is this law enforcement agency in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Law Enforcement Agency in the U.S. Address.

What is the address for this law enforcement agency?

Street (include Apt #, Unit #, or Suite #, if applicable)	[ Text ]
City	[ Text ]
State or Territory	[ Dropdown ]
ZIP Code	[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Law Enforcement Agency Not in the U.S.

Where is this law enforcement agency located?

City	[ Text ]
Country	[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Questions.

Were you arrested for this offense?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Arrested.

Did the same law enforcement agency you listed above arrest you?

[] Yes

[] No

[3] Branch Auto Populate Affirmative Answer for Arrested Another Law Enforcement Agency.

What is the name of the law enforcement agency that arrested you? (Do not use acronyms.)	[ Text ]
Is this law enforcement agency in the U.S.?		[] Yes	[] No

[2] Branch Auto Populate Affirmative Answer for Arrested Another Law Enforcement Agency. Location in the U.S.

What is the address for this law enforcement agency?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Arrested Another Law Enforcement Agency. Location Not in the U.S.

Where is this law enforcement agency located?

City	[ Text ]
Country	[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Questions Court Details.

Did you go to court or are you waiting to go to court?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Questions Details. Fined Question.

Were you fined?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Affirmative Answer for Fined.

How much was this fine?

[ Text ]

Did you pay this fine in full?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Affirmative Answer for Fined Paid in Full.

When did you pay this fine in full?

[ mm/yyyy ]

[] Estimated

[4] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Fined Not Paid in Full. Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Additional Questions Details. Fined Question Fine not paid.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance.

What is the name of the court you appeared in or are to appear in? (Do not use acronyms.)		[ Text ]
Is this court in the U.S.?			[] Yes		[] No

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Location in the U.S.

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)		[ Text ]
City		[ Text ]
State or Territory	[ Dropdown ]
ZIP Code		[ Text ]

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Location Not in the U.S.

Where is this court located?

City		[ Text ]
Country	[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Charge.

What is or was your charge? (If there is more than one charge for this offense, input one charge at a time. There will be an opportunity to input multiple entries.)		[ Text ]
What type of charge is this?	[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance . Charge Selection of “Other” in Dropdown Menu. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome.

What was the outcome for this charge?

[ Dropdown ]

[1] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of “Other” in Dropdown Menu.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Dismissed.

What were the specific court requirements you had to complete before this charge was dismissed or disposed of? (Select all that apply.)

[ Dropdown ]

Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Awaiting Trial.

When is your court date?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of On Trial.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty.

Were you sentenced?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Not Sentenced.

When is your sentencing?

[ mm/yyyy ]

[] Estimated

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced.

What was your sentence? (Select all that apply.)

[ Dropdown ]

[4] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced. Selection of “Other” Type of Sentence in Dropdown.

Please explain.

[ Text ]

[4] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced.

Were you sentenced to incarceration?

[] Yes

[] No

When were you incarcerated?

From	[ mm/yyyy ]	[] Estimated
To	[ mm/yyyy ]	[] Estimated
What is the name of the facility in which you were incarcerated? (Do not use acronyms.)	[ Text ]

[5] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced. Imprisoned. Location of Facility.

Is this facility in the U.S.?

[] Yes

[] No

[6] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced. Location of Facility in the U.S.

What is the address of this facility?

Street	[ Text ]
City	[ Text ]
State or Territory	[ Dropdown ]
ZIP Code	[ Text ]

[6] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced. Location of Facility Not in the U.S.

Where is this facility located?

City	[ Text ]
Country	[ Dropdown ]

[4] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced. Imprisoned. Additional Question.

Were you granted parole or supervised release?

[] Yes

[] No

[5] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Sentenced. Imprisoned. Parole or Supervised Release.

What are or were the dates of your parole or supervised release?

From	[ mm/yyyy ]	[] Estimated
To	[ mm/yyyy ]	[] Estimated	[] Present

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Probation Question.

Were you given probation?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of Guilty, Probation Dates.

What are or were the dates of your probation?

From (Month/Year)	[ mm/yyyy ]	[] Estimated
To (Month/Year)	[ mm/yyyy ]	[] Estimated	[] Present

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Any other Charge for the Offense Listed. Case Closed Question.

Do you have another charge for this offense to report?		[] Yes	[] No
Is your case closed?		[] Yes	[] No

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Any other Instances. Case Closed Date.

When was your case closed?

[ mm/yyyy ]

[] Estimated

[3] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Any other Instances. Case Not Closed Explanation.

Please explain.

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer to Any of the Police Record Questions Above. Any other Offense to Report.

Do you have another offense to report?

[] Yes

[] No

*** END OF BRANCH ***

Section 19 - Use of Alcohol and Rehabilitative Actions

This section asks for information regarding the extent of your alcohol consumption, its impacts on your personal and professional activities, if any, and any actions you have taken to overcome alcohol-related concerns, as applicable.

Has the use of alcohol negatively impacted your life in the past five years or since the age of 16 (if you are under 21)? (For example, have you experienced poor work or school performance; professional or personal relationship problems; or, financial, legal, or health issues?)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer on Use of Alcohol Negatively Impacting.

How has your alcohol use negatively impacted your life?

[ Text ]

When was your life negatively affected?

From

[ mm/yyyy ]

[] Estimated

To

[ mm/yyyy ]

[] Estimated

[] Present

*** End Of Branch ***

Were you ordered to get counseling or treatment as a result of alcohol use in the past five years or since the age of 16 (if you are under 21)?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment.

Who ordered you to get this counseling or treatment? (Check one. There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment with Selection of “Other” Answer.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Additional Questions.

Did you get this counseling or treatment?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Affirmative to Getting Counseling Ordered. Dates and Name of Provider

When did you get this counseling or treatment?

From

[ mm/yyyy ]

[] Estimated

To

[ mm/yyyy ]

[] Estimated

[] Present

Who is or was your counselor or treatment provider?

[ Text ]

[] I Don't Know

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Suffix	[ Dropdown ]
		[] None

[3] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider Phone Numbers.

What is their phone number? (You may list more than one.)

[Ctry|Num|Ext|Type]

[] [Day/Night/Both]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider’s email Address.

What is their email address? (You may list more than one.)

[ Address + Type ]

[] I Don't Know

[3] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider Location.

Is your counselor, treatment provider, or the practice in the U.S.?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider Location in the U.S.

What is the address of your counselor, treatment provider, or the practice?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory	[ Dropdown ]
ZIP Code	[ Text ]
Is this a U.S. military installation?		[] Yes	[] No

[5] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider Location on a Military Installation. Name of Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[4] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider Location Not in the U.S.

Where is your counselor, treatment provider, or the practice located?		[] I Don't Know
City	[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?

[] Yes

[] No

[5] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Provider Location on Military Installation. Zip Address.

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[3] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Ordered Treatment Completed.

Did you complete this counseling or treatment?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Negative Answer for Ordered Treatment Completed. Status.

What is the current status of your counseling or treatment?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Negative Answer to Getting Counseling Ordered. Explanation.

Please explain. (Include why you did not get this counseling or treatment, the consequences of not getting it, if any, and any other details you think are important.)

[ Text ]

[1] Branch Auto Populate for Affirmative Answer on Ordered Counseling or Treatment. Additional Instance.

Do you have another instance where you were ordered to get counseling or treatment as a result of your alcohol use in the past five years or since the age of 16 (if you are under 21) to report?

[] Yes

[] No

*** End Of Branch ***

Have you voluntarily been to counseling or treatment as a result of your alcohol use in the past five years or since the age of 16 (if you are under 21)?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years.

Was this voluntary counseling based on advice or a recommendation from one or more of the following? (Select all that apply.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Selection of “Other” in Dropdown Option.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Additional Questions.

When did you get this counseling or treatment?

From

[ mm/yyyy ]

[] Estimated

To

[ mm/yyyy ]

[] Estimated

[] Present

Who is or was your counselor or treatment provider?

[ Text ]

[] I Don't Know

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Suffix	[ Dropdown ]	[] None
Does your counselor or treatment provider still practice?		[] Yes	[] No
		[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Branch Auto Populate Affirmative Answer for Provider Still Practicing.

What is the name of the practice?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider Phone Numbers.

What is their phone number? (You may list more than one.)

[Ctry|Num|Ext|Type]

[] [Day/Night/Both]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider Email Addresses.

What is their email address? (You may list more than one.)

[ Addr + Type ]

[] I Don't Know

[2] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider Location.

Is your counselor, treatment provider, or the practice in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider Still Practicing in US. Address.

What is the address of your counselor, treatment provider, or the practice?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider on a Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[3] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider Address Not in the U.S.

Where is your counselor, treatment provider, or the practice located?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address)

City

[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?

[] Yes

[] No

[4] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Provider on Military Installation or Diplomatic Facility. Address.

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Counseling Completed Question.

Did you complete this counseling or treatment?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer on Voluntarily Received Counseling or Treatment in Past Five Years. Counseling Not Completed

What is the current status of your counseling or treatment?

[ Text ]

*** End Of Branch ***

Section 20 - Relationship Status

This section asks for information regarding your current relationship status. We also ask for general information regarding former legally-recognized spouses or partners, as applicable. For purposes of this form, the term "committed, spouse-like relationship" is defined as a relationship between two people who are not in a legally-recognized marriage, union, or domestic partnership, present themselves as a couple, and live together continuously.

What is your current relationship status?

[ Dropdown ]

[1] Branch Auto Populate for Relationship Status of in a Marriage/Union/Domestic Partnership/Common Law Marriage/Committed Spouse-Like Relationship/Separated.

What is the name of your spouse or partner?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

What is their date of birth?

[ mm/dd/yyyy ]

[] Estimated

[2] Branch Auto Populate Place of Birth for Spouse or Partner.

Were they born in the U.S.? (The U.S. is defined as the 50 U.S. states, the District of Columbia, and the U.S. territories.)

[] Yes

[] No

[3] Branch Auto Populate for Place of Birth in U.S. for Spouse or Partner.

Where were they born?

City

[ Text ]

County Or County Equivalent

[ Text ]

State or Territory

[ Dropdown ]

[3] Branch Auto Populate for Place of Birth Not in U.S for Spouse or Partner.

Where were they born?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate Citizenship for Spouse or Partner.

Provide country(ies) of citizenship. (Select all that apply.)

[ Dropdown ]

What is their citizenship status?

[ Dropdown ]

[3] Branch Auto Populate Spouse or Partner U.S. Citizen Born Abroad

What document do they have proving they are a U.S. citizen born abroad?

[ Dropdown ]

[4] Branch Auto Populate Other Documentation for Spouse or Partner U.S. Citizen Born Abroad

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[4] Branch Auto Populate Other Documentation for Spouse or Partner U.S. Citizen Born Abroad. Document Serial Numbers

What is the serial number on the document? (This is typically the number in the top right-hand corner of the document, often in red ink.)	[ Text ]	[] No Number
		[] I Don't Know

[3] Branch Auto Populate Other Documentation for Spouse or Partner U.S. Citizen Born Abroad. Other Documents. Expiration Date. If Applicable

What is the expiration date of this document?

[ mm/dd/yyyy ]

[] Not Applicable

[] I Don't Know

[3] Branch Auto Populate Spouse or Partner Naturalized U.S. Citizen.

What document do they have proving they are a naturalized U.S. citizen?

[ Dropdown ]

[4] Branch Auto Populate Other Documentation for Spouse or Partner Naturalized U.S. Citizen

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[4] Branch Auto Populate for Spouse or Partner Alien Registration Number on Certificate of Citizenship.

What is their U.S. Alien Registration Number? • You can find their Alien Registration Number on their Certificate of Naturalization (N-550 or N-570). It is a 7- to 9-digit number typically listed as the "USCIS Registration No.", "INS Registration No.", "CIS Registration No." It is not the "No." (short for number) in the top right hand corner often seen in red ink.

[ Text ]

[] I Don't Know

[4] Branch Auto Populate for Spouse or Partner Naturalization Certificate Number

What is their Naturalization Certificate Number or Naturalization Number? • This is the "No." (short for number) in the top right hand corner of their Certificate of Naturalization (N-550 or N-570). It is often in red ink.

[ Text ]

[] I Don't Know

[4] Branch Auto Populate for Spouse or Partner Alien Registration Number on Permanent Resident Card.

What is their U.S. Alien Registration Number? • You can find their Alien Registration Number on their Permanent Resident Card/Resident Alien Card (Form I-551). It is a 7- to 9-digit number typically listed as the "A#", "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV), it is the "Registration Number".

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Spouse or Partner Other Documents Expiration Date as Applicable.

What is the expiration date of this document?	[ mm/dd/yyyy ]	[] Estimated	[] Not Applicable
		[] I Don't Know

[3] Branch Auto Populate Spouse or Partner Other Derived Document.

What document do they have proving they are a derived U.S. citizen?

[ Dropdown ]

[4] Branch Auto Populate Spouse or Partner Selection of “Other” Derived Document.

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number [] I Don't Know

[4] Branch Auto Populate Spouse or Partner Derived Document Alien Registration Number

What is their U.S. Alien Registration Number? • You can find their Alien Registration Number on their Certificate of Citizenship (Form N-560 or Form N-561). It is the 7- to 9-digit number typically listed as the "USCIS Registration No.", "CIS Registration No.", or "INS Registration No.".

[ Text ]

[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Other Citizenship Certificate Document

What is their Citizenship Certificate Number/Citizenship Number? • This is the "No." (short for number) in the top right hand corner of their Certificate of Citizenship (Form N-560 or Form N-561). It is often in red ink.

[ Text ]

[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Alien Registration Number on Permanent Resident Card

What is their U.S. Alien Registration Number? • You can find their Alien Registration Number on their Permanent Resident Card/Resident Alien Card (Form I-551). It is a 7- to 9-digit number typically listed as the "A#", "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV), it is the "Registration Number".

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Spouse or Partner Other Derived Document Expiration Date.

What is the expiration date of this document?	[ mm/dd/yyyy ]	[] Estimated	[] Not Applicable
		[] I Don't Know

[3] Branch Auto Populate Spouse or Partner Not U.S. Citizen

What is their residence status?

[ Dropdown ]

[4] Branch Auto Populate Spouse or Partner Not U.S. Citizen Explanation

Please explain.

[ Text ]

[3] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S.

What document do they have proving they are authorized to be in the U.S.?

[ Dropdown ]

[4] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Document Information

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Alien Registration Number

What is their U.S. Alien Registration Number? • You can find their Alien Registration Number on their Permanent Resident Card/Resident Alien Card (Form I-551) or on their Employment Authorization Card (Form I-766), as applicable. Their Alien Registration Number may be listed as the "A#", "A" number, "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV) Form I-551, it is the "Registration Number".

[ Text ]

[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Non-Citizen Authorization Document (I-94)

What is the document number? • For the Form I-94, list the 11-digit number labeled either "Admission Number", "Departure Number", "Admission Record (I-94) Number", or "I-94#". Or, they may have an "Admission Stamp" in their unexpired Foreign Passport. If this is the case, also list their Passport Number and the Country that issued the passport.

[ Text ]

[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Non-Citizen Authorization Document (US Visa Card)

What is the document number? • For the U.S. Visa Card (nonimmigrant visa) -- the visa number, also called a visa foil number, is a red number that is generally printed on the bottom right corner of newer visa documents. In most cases, the U.S. visa number contains eight numeric characters. In some cases, the number contains one letter followed by seven numeric characters.

[ Text ]

[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Non-Citizen Authorization Document (I-20)

What is the document number? • For the Form I-20, list the "SEVIS ID" number near the top left or top right corner of the document (depending on the document version). All SEVIS ID numbers start with the letter N. If they also have an "Admission Number" on their Form I-20 document, list this number as well (this is their Form I-94 number).

[ Text ]

[] I Don't Know

[4] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Non-Citizen Authorization Document (DS-2019)

What is the document number? • For the Form DS-2019, list the number on the top right hand side of the page in the box above the barcode. This is the SEVIS number. All SEVIS ID numbers start with the letter N.

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Spouse or Partner Other Document Authorizing Being in the U.S. Expiration Date

What is the expiration date of this document?	[ mm/dd/yyyy ]	[] Estimated	[] Not Applicable
		[] I Don't Know

[2] Branch Auto Populate Spouse or Partner. Additional Questions

What is their U.S. Social Security Number?

[ ###-##-#### ]

[] Not Applicable

Have they ever used a different name?

[] Yes [] I Don’t Know

[] No

[3] Branch Auto Populate for Affirmative Answer on Other Names Used by Spouse or Partner

What other name have they used?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

Which of the following best describes this name?

[ Dropdown ]

[4] Branch Auto Populate Explanation of Other Names Used by Spouse or Partner

Please explain.

[ Text ]

[3] Branch Auto Populate Dated Other Names Used by Spouse or Partner

When did they use this name?

[] I Don't Know

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month/Year)

[ mm/yyyy ]

[] Estimated

[] Present

Do they have another name you need to report?

[] Yes

[] No

[3] Branch Auto Populate Beginning Date of Relationship with Spouse or Partner (if in Committed Spouse-like Relationship)

When did you enter this relationship?

[ mm/dd/yyyy ]

[] Estimated

[3] Branch Auto Populate Spouse or Partner Relationship Union Details (if Marriage, Union, Domestic Partnership, Common Law Marriage or Separated)

When did you enter this civil marriage, civil union, domestic partnership, or common law marriage?

[ mm/dd/yyyy ]

[] Estimated

Did you enter this civil marriage, civil union, domestic partnership, or common law marriage while in the U.S.?

[] Yes

[] No

[4] Branch Auto Populate Spouse or Partner for Affirmative Answer on Relationship Union in the U.S.

Where did you enter this civil marriage, civil union, domestic partnership, or common law marriage?

City

[ Text ]

County Or County Equivalent

[ Text ]

State or Territory

[ Dropdown ]

[4] Branch Auto Populate for Spouse or Partner (if Marriage, Union, Domestic Partnership, Common Law Marriage or Separated) for Affirmative Answer on Relationship Union but Not in the U.S.

Where did you enter this civil marriage, civil union,

domestic partnership, or common law marriage?

City

[ Text ]

Country

[ Dropdown ]

[3] Branch Auto Populate Spouse or Partner Lives Same Address

Do they live with you at the same address?

[] Yes

[] No

[4] Branch Auto Populate Affirmative Answer on Spouse or Partner Lives Same Address Location.

Do they live in the U.S.?

[] Yes

[] No

[5] Branch Auto Populate Affirmative Answer on Spouse or Partner Living Same Location in the U.S.

What is their address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?

[] Yes

[] No

[6] Branch Auto Populate Affirmative Answer on Spouse or Partner Living Same Location on a Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[5] Branch Auto Populate Affirmative Answer on Spouse or Partner Living Same Location not in the U.S.

Where do they live?

Please provide physical address [ Text ] (not mailing address)

City

[ Text ]

Country

[Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?

[] Yes

[] No

[6] Branch Auto Populate Affirmative Answer on Spouse or Partner Lives on a Military Installation.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[2] Branch Auto Populate Affirmative Answer on Spouse or Partner. Phone Number.

What is their phone number?

[Ctry|Num|Ext|Type]

[] [Day/Night/Both]

[] I Don't Know

[2] Branch Auto Populate Affirmative Answer on Spouse or Partner. Email Address.

What is their email address?

[ Addr + Type ]

[] I Don't Know

[2] Branch Auto Populate Affirmative Spouse or Partner. Relationship Type as Separated. Details Question

When did you legally separate?

[ mm/dd/yyyy ]

[] Estimated

Are the legal documents for your separation recorded in the U.S.?

[] Yes

[] No

What is the name of the government office where your separation documents are recorded? (Do not use acronyms or abbreviations.)

[ Text ]

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Type as Separated. Affirmative Answer on Separation Recorded in the U.S. Address.

Where are they recorded?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Type as Separated. Separation Not Recorded in the U.S. Location.

Where are they recorded?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Details Questions.

What is the name of the person you were in a civil marriage, civil union, domestic partnership, or common law marriage with?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

What is their date of birth?

[ mm/dd/yyyy ]

[] Estimated

Were they born in the U.S.? (The U.S. is defined as the 50 U.S. states, the District of Columbia, and the U.S. territories.)

[] Yes

[] No

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Place of Birth in the U.S.

Where were they born?

City

[ Text ]

County Or County Equivalent

[ Text ]

State or Territory

[ Dropdown ]

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Place of Birth Not in the U.S.

Where were they born?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Citizenship and Deceased Question.

Provide country(ies) of citizenship. (Select all that apply.)

[ Dropdown ]

Is this person deceased?

[] Yes

[] No

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Phone Number

What is their phone number?

[Ctry|Num|Ext|Type]

[] [Day/Night/Both]

[] I Don't Know

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Email Addresses

What is their email address? (You may list more than one.)

[ Addr + Type ]

[] I Don't Know

[2] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Union Dates & Location.

When did you enter this civil marriage, civil union, domestic partnership, or common law marriage?

[ mm/dd/yyyy ]

[] Estimated

Did you enter this civil marriage, civil union, domestic partnership, or common law marriage while in the U.S.?

[] Yes

[] No

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Entered Union in the U.S. Location.

Where did you enter this civil marriage, civil union, domestic partnership, or common law marriage?

City

[ Text ]

County Or County Equivalent

[ Text ]

State or Territory

[ Dropdown ]

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Entered Union Not in the U.S. Location.

Where did you enter this civil marriage, civil union, domestic partnership, or common law marriage?

City

[ Text ]

Country

[ Dropdown ]

[2] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Divorced/Annulled Dates and Last Known Address.

What is the date of your divorce, dissolution, or annulment?

[ mm/dd/yyyy ]

[] Estimated

Is this person's last known address in the U.S?

[] Yes

[] No

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Last Known Address in the U.S. Address Information.

What is the address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?

[] Yes

[] No

[4] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Last Known Address on Military Installation

What is the name of the U.S. military installation?

[ Text ]

[3] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Last Known Address Not in the US

Where do they live?

[] I Don't Know

Please provide physical address [ Text ] (not mailing address).

City

[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?

[] Yes

[] No

[4] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Divorced/Annulled. Former Spouse or Partner Alive. Last Known Address on Military Installation

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[2] Branch Auto Populate Affirmative Spouse or Partner. Relationship Status as Widowed. Details Questions

What is your deceased spouse or partner's name?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

When did they die?

[ mm/dd/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Spouse or Partner. Any Other Former Legally-recognized Spouse or Partner.

Do you have a former legally-recognized spouse or partner that you have not reported on this form?

[] Yes

[] No

*** End Of Branch ***

Section 21 - Relatives

If you have not had any contact with a relative select the box "[] No contact with family member" but you must still provide information about your relative to the best of your knowledge. If there is a safety reason for which you do not wish to provide your relative’s information, contact the office that asked you to complete this form. However, you must still provide the information about your relative to the best of your knowledge. As noted in the instructions, the information you provide is protected under the Privacy Act and will be protected from unauthorized disclosure.

Who are your relatives? (Check one. There will be an opportunity to input multiple entries. List your mother even if you already provided her name in Part A of this form. List all relatives even if deceased.)

[ Dropdown ]

[1] Branch Auto Populate Relative Name & Details

What is your relative's name?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[ ] No Contact with Family Member

What is your relative’s date of birth?

[ mm/dd/yyyy ]

[] Estimated

[] I Don't Know

Was your relative born in the U.S.? (The U.S. is defined as the 50 U.S. states, the District of Columbia, and the U.S. territories.)		[] Yes [] I Don't Know	[] No

[2] Branch Auto Populate Affirmative Answer on Relatives U.S. Born

Where were they born?

City

[ Text ]

County Or County Equivalent

[ Text ]

State or Territory

[ Dropdown ]

[2] Branch Auto Populate Relatives Not Born in the U.S.

Where were they born?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate Relative Citizenship.

Provide country(ies) of citizenship for this relative. (Select all that apply.)

[ Dropdown ]

[1] Branch Auto Populate Relative Deceased.

Is this person deceased?		[] Yes	[] No
		[] I Don't Know

[2] Branch Auto Populate Relative. Alive. Other Names

Has your relative ever used a different name?

[] Yes

[] No

[4] Branch Auto Populate Relative. Alive. Other Names Details

What other name have they used? For all listed relatives, you must include the name on their birth certificate.

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix

[ Dropdown ]

Which of the following best describes this name?

[ Dropdown ]

[4] Branch Auto Populate Relative. Alive. Selection of “Other” for Dropdown menu above.

Please explain.

[ Text ]

[3] Branch Auto Populate Relative. Alive. Other Names Additional Questions.

When did they use this name?

[] I Don't Know

From (Month/Year)

[ mm/yyyy ]

[] Estimated

To (Month/Year)

[ mm/yyyy ]

[] Estimated

[] Present

Do they have another name you need to report?

[] Yes

[] No

[2] Branch Auto Populate Relative. Alive. Residence Location.

Does this relative live in the U.S?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Residence Location In US

What is their address? (List their last known address if you do not know their current address.)

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate Relative. Alive. Residence Location in the U.S. on Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Residence Location Not in the U.S. Location.

Where do they live?

Please provide physical address [ Text ] (not mailing address)

City

[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate Relative. Alive. Residence Location not in the U.S. Affirmative for on a Military Installation.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[1] Branch Auto Populate Relative. Alive. Citizenship Status.

What is their citizenship status?	[ Dropdown ]	[] I Don't Know

[2] Branch Auto Populate Relative. Alive. Citizenship Status: U.S. Born Abroad. Document Type.

What document do they have verifying they are a U.S. citizen born abroad?

[ Dropdown ]

[3] Branch Auto Populate Relative. Alive. Citizenship Status: U.S. Born Abroad. Document Selection of “Other” in Dropdown Menu.

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Citizenship Status: U.S. Born Abroad. Document Selection (FS-240, DS-1350, FS-545, N-560, N-561) Questions.

What is the serial number on the document? (This is typically the number in the top right-hand corner of the document (it is often in red ink).)	[ Text ]	[] No Number
		[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Citizenship Status: U.S. Born Abroad. Document Expiration.

What is the expiration date of this document?

[ mm/dd/yyyy ]

[] Not Applicable

[] I Don't Know

[2] Branch Auto Populate Relative. Alive. Citizenship Status: Naturalized. Document Type.

What document do they have proving they are a naturalized U.S. citizen?

[ Dropdown ]

[3] Branch Auto Populate Relative. Alive. Citizenship Status: Naturalized. Document Type Selection of “Other” in Dropdown.

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Citizenship Status: Naturalized. Naturalized Document Information for Selection of N-550 or N-570 Document.

What is their U.S. alien registration number? • You can find their alien registration number on their Certificate of Naturalization (N-550 or N-570). It is a 7- to 9-digit number typically listed as the "USCIS Registration No.", "INS Registration No.", "CIS Registration No." It is not the "No." (short for number) in the top right hand corner often seen in red ink.

[ Text ]

[] I Don't Know

What is their Naturalization Certificate Number/ Naturalization Number? • This is the "No." (short for number) in the top right hand corner of their Certificate of Naturalization (N-550 or N-570). It is often in red ink.

[ Text ]

[] I Don't Know

What is the name of the court that issued the Certificate of Naturalization (N-550 or N-570)? (Do not use acronyms or abbreviations.)

[ Text ]

[] I Don't Know

What is the court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[3] Branch Auto Populate Relative. Alive. Citizenship Status: Naturalized. Naturalized Document Information for Selection of Naturalized Document I-551 or Machine Readable Immigrant Visa

What is their U.S. alien registration number? • You can find their alien registration number on their Permanent Resident Card/Resident Alien Card (Form I-551). It is a 7- to 9-digit number typically listed as the "A#", "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV), it is the "Registration Number".

[ Text ]

[] I Don't Know

[2] Branch Auto Populate Relative. Alive. Citizenship Status: Naturalized. Document Expiration.

What is the expiration date of this document?	[ mm/dd/yyyy ]	[] Estimated	[] Not Applicable
		[] I Don't Know

[2] Branch Auto Populate Relative Derived U.S. Citizenship Documentation.

What document do they have proving they are a derived U.S. citizen?

[ Dropdown ]

[3] ] Branch Auto Populate Relative. Alive. Citizenship Status: Derived U.S. Citizenship Selection of “Other” Under Documentation Dropdown.

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Citizenship Status: Derived U.S. Citizenship Documents N-560, N-561.

What is their U.S. alien registration number? • You can find their alien registration number on their Certificate of Citizenship (Form N-560 or Form N-561). It is the 7- to 9-digit number typically listed as the "USCIS Registration No.", "CIS Registration No.", or "INS Registration No.".

[ Text ]

[] I Don't Know

What is their Citizenship Certificate Number/Citizenship Number? • This is the "No." (short for number) in the top right hand corner of their Certificate of Citizenship (Form N-560 or Form N-561). It is often in red ink.

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative. Alive. Citizenship Status: Derived U.S. Citizenship Document I-551.

What is their U.S. alien registration number? • You can find their alien registration number on their Permanent Resident Card/Resident Alien Card (Form I-551). It is a 7- to 9-digit number typically listed as the "A#", "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV), it is the "Registration Number".

[ Text ]

[] I Don't Know

What is the expiration date of this document?	[ mm/dd/yyyy ]	[] Estimated	[] Not Applicable
		[] I Don't Know

[2] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S.

What is their residence status?	[ Dropdown ]	[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Residency Status Selection of “Other” Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type.

What document do they have proving they are authorized to be in the U.S.?

[ Dropdown ]

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type Selection of “Other” in Dropdown.

What is the title of the form?

[ Text ]

What is the document number on the form? (This is not the form number. The document number may be listed as a registration number, serial number, or other number distinct to the person.)	[ Text ]	[] No Number
		[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type Selection of Documents I-551, I-766, or Machine Readable Immigrant Visa.

What is their Alien Registration Number? • You can find their alien registration number on their Permanent Resident Card/Resident Alien Card (Form I-551) or on their Employment Authorization Card (Form I-766), as applicable. Their Alien Registration Number may be listed as the "A#", "A" number, "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV) Form I-551, it is the "Registration Number".

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type Selection of Document I-94.

What is the document number? • For the Form I-94, list the 11-digit number labeled either "Admission Number", "Departure Number", "Admission Record (I-94) Number", or "I-94#". Or, they may have an "admission stamp" in their unexpired foreign passport. If this is the case, also list their passport number and the country that issued the passport.

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type Selection of U.S. Visa Card Document.

What is the document number? • For the U.S. Visa Card (nonimmigrant visa) -- the visa number, also called a visa foil number, is a red number that is generally printed on the bottom right corner of newer visa documents. In most cases, the U.S. visa number contains eight numeric characters. In some cases, the number contains one letter followed by seven numeric characters.

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type Selection of Document I-20.

What is the document number? • For the Form I-20, list the "SEVIS ID" number near the top left or top right corner of the document (depending on the document version). All SEVIS ID numbers start with the letter N. If they also have an "Admission Number" on their Form I-20 document, list this number as well (this is their Form I-94 number).

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type Selection of Document DS-2019.

What is the document number? • For the Form DS-2019, list the number on the top right hand side of the page in the box above the barcode. This is the SEVIS number. All SEVIS ID numbers start with the letter N.

[ Text ]

[] I Don't Know

[2] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Expiration Date.

What is the expiration date of this document?	[ mm/dd/yyyy ]	[] Estimated	[] Not Applicable
		[] I Don't Know

[2] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Additional Question. Any Contact.

Have you ever been in contact with this relative?

[] Yes

[] No

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Contact with Non-U.S. Citizen Relative Information.

When was your first contact with this relative?

[ mm/yyyy ]

[] Estimated

When was your last contact with this relative?

[ mm/yyyy ]

[] Estimated

What methods do you and this relative use to contact one another? (Select all that apply.)

[ Dropdown ]

[4] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Contact with Non-U.S. Citizen Relative Information. Contact Method Selection of “Other” in Dropdown Menu.

Please explain.

[ Text ]

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Contact with Non-U.S. Citizen Relative Information. Frequency of Contact.

How often are you in contact with this relative?

[ DROPDOWN ]

[4] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Contact with Non-U.S. Citizen Relative Information. Frequency of Contact Selection of “Other” in Dropdown Menu Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen. Additional Questions.

Who does your relative work for? (If your relative is unemployed, then provide the name of their most recent employer).	[ Text ]	[] Never Worked [] I Don't Know
If known, what is your relative’s occupation?	[Text]

Is your relative's employer located in the U.S.?

[ Text ]

[] Not Applicable

[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen with Employer Located in the U.S. Address.

What is the address of their employer?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen with Employer Located in the U.S. Address on Military Installation.

What is the name of the U.S. military installation?

[ Text ]

[] I Don't Know

[3] Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S. Citizen with Employer Not Located in the U.S. Location.

Where is their employer located?

City

[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?		[] Yes	[] No
		[] I Don't Know

[4] Branch Auto Populate Affirmative Answer for Relative. Alive. Non-Citizen with Employer Address not in US and on Military Installation.

What is the name of the U.S. military installation or U.S. diplomatic facility?	[ Text ]	[] I Don't Know
		[] Not Applicable

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate Affirmative Answer for Relative. Alive. Foreign Relative Government Relationship Question.

Is this relative affiliated with a foreign (non-U.S.) government, military, security service, defense industry, movement, or intelligence service?		[] Yes	[] No
		[] I Don't Know

[3] Branch Auto Populate Affirmative Answer for Relative. Alive. Affirmative Answer Foreign Government Relationship.

What is your relative’s relationship with this foreign (non-U.S.) government, military, security, defense industry, movement, or intelligence service?

[ Text ]

[] I Don't Know

[2] Branch Auto Populate Affirmative Answer for Another Relative.

Do you have another relative to report? (You must list all relatives even if deceased.)

[] Yes

[] No

*** End Of Branch ***

Section 22 - Foreign Travel

This section asks for information regarding foreign countries you have traveled to in the past 5 years and the purpose of those trips. (Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.) We also want to know of any encounters you had with the foreign government, police, or any individuals showing an undue interest in you on these trips, as applicable.

• Foreign means non-U.S. -- that is, outside of the 50 U.S. states, District of Columbia, and U.S. territories.

• List personal trips taken in conjunction with duty performed while on U.S. government or military orders. Examples of personal trips include vacations, side trips, or other unofficial travel made for personal reasons.

• Each entry into and out of a country is a new trip (this includes layovers).

• Do not list travel where you were on official U.S. government or military orders.

• Do not list foreign travel you previously listed on this form.

Have you traveled to a foreign country in the past five years? (Do not list travel where you were on U.S. government or military orders. Do list personal trips taken in conjunction with work performed while on U.S. government or military orders.)

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Travel Summary Questions.

Which foreign country did you travel to?

[ Dropdown ]

When did you travel to this country?

From

[ mm/yyyy ]

[] Estimated

To

[ mm/yyyy ]

[] Estimated

[] Present

How long was this trip?

[ Dropdown ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Reason for Travel.

Why did you travel to this country? (Select all that apply.)

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Reason for Travel. Selection of “Other” in Dropdown Menu. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Questioned/Searched/Detained Question.

While traveling to, from, or within this country, were you questioned, searched, or otherwise detained by customs, security officials, or any other entity? (This does not include those conducted as part of the normal customs' process.)

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Branch Auto Populate Affirmative Answer for Questioned/Searched/Detained. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Police Interaction Question.

While traveling to, from, or within this country, did you have any encounters with the police?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Affirmative Answer Police Interaction. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Contact with Foreign Intelligence Personnel Question While Traveling.

While traveling to, from, or within this country, did you have contact with any person who you know or suspect is involved or associated with a foreign military, intelligence service, diplomatic service, security service, militia, other defense force, government agency?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Affirmative Answer to Contact with Foreign Intelligence Personnel While Traveling. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Potential Security Concerns Question While Traveling.

While traveling to, from, or within this country, did you have any incidents that were a potential security concern or considered suspicious activity, such as someone following you?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Affirmative Answer to Potential Security Concerns Question While Traveling.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Contact with Person with Interest on Individual’s Work.

While traveling to, from, or within this country, did you have contact with anyone who exhibited excessive knowledge of, or had undue interest in, you or your work?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer to Contact with Person with Interest on Individual’s Work Interest. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Attempt to Gain Access to Classified Information Question.

While traveling to or within this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive information?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Affirmative Answer for Attempt to Gain Access to Classified Information Question. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Contact with Person Who Threatened, Coerced or Pressured Cooperation with Foreign Government/Office.

While traveling to, from, or within this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official (such as from a foreign military, intelligence service, diplomatic service, security service, a militia, other defense forces)?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreign Travel. Affirmative Answer to Contact with Person Who Threatened, Coerced or Pressured Cooperation with Foreign Government/Office. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreign Travel. Additional Travel.

Do you have another foreign country that you traveled to in the past five years to report? (Do not list travel where you were on U.S. government or military orders. Do list personal trips taken in conjunction with work performed while on U.S. government or military orders.)

[] Yes

[] No

*** End Of Branch ***

Section 23 - Financial Record

This section asks for information regarding your finances to include any bankruptcies, judgments, liens, foreclosures, repossessions, evictions, charged-off accounts, debts over 120-days past due, including alimony or child support payments, and any wage, benefit, or asset seizures, as applicable. We also want to know what activities you have taken to address any past due financial obligations.

For this section, the term past due:

• Means a payment was not made by its due date, or by the end of the grace period, if applicable.

• For credit card accounts, past due means the minimum required payment was not applied to the account as of the due date, or by the end of the grace period, if applicable.

• For other debts paid in installments, such as loans, past due means a payment was not made by its due date or by the end of the grace period.

Have you filed for bankruptcy in the past five years?

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Bankruptcy in Past Five Years.

Which chapter of the U.S. Bankruptcy Code did you file under? Was the bankruptcy filed jointly with another individual? Name of Individual

[ Dropdown ] [] Yes [Text]

[] No

[1] Branch Auto Populate Affirmative Answer for Bankruptcy in Past Five Years. Additional Questions for All Types of Bankruptcy.

What is the court docket or account number for this bankruptcy?

[ Text ]

[] I Don't Know

What is the name of the bankruptcy court that handled this bankruptcy? (Do not use acronyms or abbreviations.)

[ Text ]

Where is this bankruptcy court located?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

County Or County Equivalent

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

When did you file your bankruptcy paperwork with the bankruptcy court?

[ mm/yyyy ]

[] Estimated

How much money (in U.S. dollars) was involved in this bankruptcy?

[ Text ]

[] Estimated

What name did you use to file this bankruptcy?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[2] Branch Auto Populate Affirmative Answer for Bankruptcy in Past Five Years. Additional Questions for Chapters 12 and 13.

What is the name of the bankruptcy administrator or trustee for this bankruptcy?

[ Text ]

[] I Don't Know

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

What is their address?

[] I Don't Know

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Bankruptcy in Past Five Years. Bankruptcy Discharged.

Was this bankruptcy discharged? (This means you were released from any obligation to repay the debts claimed in your bankruptcy.)

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Bankruptcy in Past Five Years. Discharged.

When was this bankruptcy discharged? (This is the date of the court order ending your bankruptcy proceeding.)

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for Bankruptcy in Past Five Years. Not Discharged.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Bankruptcy in Past Five Years. Another Instance.

Do you have another instance where you filed for bankruptcy in the past five years?

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you been over 120 days past due on any alimony payments?	[ Text ]	[] Yes	[] No
		[] Not Applicable (Text)

[1] Branch Auto Populate for Affirmative Answer for Past Due Alimony Payments. Specifics.

Who do or did you owe alimony to?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

How much are or were you required to pay in alimony monthly (in U.S. dollars)?

[ Text ]

How much are or were you past due (in U.S. dollars)?

[ Text ]

[] Estimated

Why are or were you past due?

[ Text ]

When did you become past due?

[ mm/yyyy ]

[] Estimated

Are you currently over 120 days past due?						[] Yes [] No
[2] Branch Auto Populate Affirmative Answer for Past Due Alimony Payments. No Longer Past Due.
When did you become current on your alimony payments?		[ mm/yyyy ]				[] Estimated
[2] Branch Auto Populate Affirmative Answer for Past Due Alimony Payments. Currently Past Due.
What actions have you taken to become current on these alimony payments?	[ Text ]		[] None

[3] Branch Auto Populate Affirmative Answer for Past Due Alimony Payments. Overdue but No Action Taken.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Past Due Alimony Payments. Court Details Questions.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the court docket or order number for these alimony payments?

[ Text ]

[] I Don't Know

Do you have another instance where you are or were over 120 days past due on alimony payments in the past five years?

[] Yes

[] No

*** End Of Branch ***

In the past five years have you been over 120 days past due on any child support payments?		[] Yes	[] No

[1] Branch Auto Populate Affirmative Answer for Overdue Child Support.

Who do or did you owe child support to?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

How much are or were you required to pay in child support monthly (in U.S. dollars)?

[ Text ]

How much are or were you past due (in U.S. dollars)?

[ Text ]

[] Estimated

Why are or were you past due?

[ Text ]

When did you become past due?

[ mm/yyyy ]

[] Estimated

Are you currently over 120 days past due?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Overdue Child Support. No Longer Overdue.

When did you become current on your child support payments?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for Overdue Child Support. Currently Overdue.

What actions have you taken to become current on these child support payments?

[ Text ]

[] None

[3] Branch Auto Populate Affirmative Answer for Overdue Child Support. Currently Overdue but No Action Taken.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Overdue Child Support. Court Details Questions.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the court docket or order number for these child support payments?

[ Text ]

[] I Don't Know

Do you have another instance where you are or were over 120 days past due on child support payments in the past five years?

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you had a civil judgment entered against you? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.) • A civil judgment is the final order of a court in a civil lawsuit. Typically, a civil judgment finds that one party owes money to another, but it could be many things depending on the facts and circumstances of the case. If a civil judgment is entered against you for money damages, you are personally liable for satisfying the debt.

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Civil Judgement in Past Five Years. Details

How much was the judgment for (in U.S. dollars)?

[ Text ]

[] Estimated

Why was this judgment entered against you?

[ Text ]

When was this judgment entered against you?

[ mm/yyyy ]

[] Estimated

Did you pay this judgment in full?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Civil Judgement in Past Five Years. Paid in Full.

When did you pay this judgment in full?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate for Affirmative Answer for Civil Judgement. Not Paid in Full.

What actions have you taken to pay this judgment in full?

[ Text ]

[] None

[3] Branch Auto Populate for Affirmative Answer for Civil Judgement. Not Paid in Full and No Action Taken.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Civil Judgement. Court Details.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the court docket or order number for this civil judgment?

[ Text ]

[] I Don't Know

Who are the parties (besides yourself) listed in this civil judgment?

[ Text ]

Do you have another instance where a civil judgment was entered against you in the past five years? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.)

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you had a lien placed against your property for failing to pay a debt? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.) • A lien is a legal claim on something you own (such as your home, land, cars, or boats). Liens allow other individuals or entities the legal right to take your property or take other legal action to satisfy your debts or obligations to them.

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Entity Placing Lien.

What type of entity placed this lien against your property?

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Lienholder is Government or Other Entity.

What is the name of the company, government agency, or other entity that placed the lien against your property? (Do not use acronyms or abbreviations.)

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Private Lienholder. Additional Information.

Who placed the lien against your property?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Lienholder Selection of “Other” in Dropdown Menu. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Property Type.

What type of property was this lien placed against?

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Property Type Selection of “Other” in Dropdown Menu.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Reason for Lien.

Why was this lien placed against your property?

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Reason for Lien Selection of “Other” in Dropdown Menu.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Additional Details

How much money do you or did you owe the lienholder (in U.S. dollars)? • A lienholder is the entity that has a legal claim, hold, or charge against your property for satisfaction of a debt. Examples of a lienholder are a mortgage company, auto financing company, child support enforcement agency, credit card company, bank, credit union, financial institution, the IRS, or a private party or individual.

[ Text ]

When was this lien placed against you?

[ mm/yy ]

[] Estimated

Is this lien still placed against your property?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Lien Released.

When was this lien resolved?

[ mm/yy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Lien Still in Place. Actions Taken.

What actions have you taken to resolve this lien?

[ Text ]

[] None

[3] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Lien Still in Place. No Action Taken. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Court Details Question.

What is the name of the government office where the lien is recorded? (Do not use acronyms or abbreviations.)

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Court Address.

What is the address for this government office?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Court Details Additional Question.

What is the case or document number associated with this lien?

[ Text ]

[] I Don't Know

Do you have another instance where a lien was placed against your property for failing to pay a debt in the past five years? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.)

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you had any property foreclosed on? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.) • Foreclosure is a process that allows lenders to take ownership of mortgaged property from the borrower. This is typically real estate (such as land, a home, or other building) in which the borrower has defaulted on the loan.

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Property Foreclosure in Past Five Years. Entity Type.

Did a public or government entity or a private party foreclose on your property?

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. If Foreclosure Entity Public or Government.

What is the name of the lender that foreclosed on your property? (Examples of commercial lenders include banks and credit unions whereas examples of government lenders include Fannie Mae, Freddie Mac, or the Veteran's Administration (VA). Do not use acronyms or abbreviations.)

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. If Foreclosure Entity is Private

Who foreclosed on your property?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. If Foreclosure Entity is Section of “Other” from Dropdown Menu. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Type of Property.

What type of property was foreclosed on?

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Selection of “Other” for Type of Property. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Foreclosure Details Questions.

What is the address of the property that was foreclosed on?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

When was your first missed mortgage payment?

[ mm/yyyy ]

[] Estimated

How many mortgage payments did you miss?

[ Text ]

[] Estimated

How much money do or did you owe the lender (in U.S. dollars)?

[ Text ]

[] Estimated

Why did you stop making mortgage payments?

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Additional Foreclosure Details. Dates, Still Owe Questions.

When was your property foreclosed on?

[ mm/yyyy ]

[] Estimated

Do you still owe money to the lender on this property?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Does Not Still Owe. Date Closed.

When was this case closed?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Still Owe. Action Taken.

What actions have you taken to pay the lender?

[ Text ]

[3] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Still Owe and No Action Take. Explanation

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Court Name.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

[] Not Applicable (Text)

[2] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Court Address.

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the court docket or order number associated with this foreclosure?

[ Text ]

[] I Don't Know

[1] Branch Auto Populate Affirmative Answer for Foreclosure in the Past Five Years. Another Instance.

Do you have another instance where your property was foreclosed on in the past five years? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.)

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you had any possessions or property repossessed? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.) • Repossession is a process that allows lienholders to recover specific possessions or property after a buyer defaults on payments. The possessions or property that are repossessed are typically bought on a payment plan via a contract (such as, vehicles, jewelry, furniture) as opposed to real estate that is foreclosed upon when the borrower defaults on payments.

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Name of Lender. Type of Property.

What is the name of the lender that repossessed your property? (Do not use acronyms or abbreviations.)

[ Text ]

What type of property was repossessed?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Selection of “Other” for Type of Property.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Details.

When was your first missed payment to the lender?

[ mm/yy ]

[] Estimated

How many payments did you miss prior to the repossession?

[ Text ]

How much money (in U.S. dollars) do or did you owe the lender?

[ Text ]

Why did you stop making payments to the lender?

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Additional Details. Still Owe.

When was your property repossessed?

[ mm/yyyy ]

[] Estimated

What is the account number associated with this repossession?

[ Text ]

[] I Don't Know

Do you still owe money to the lender for this property?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Does Not Owe

When was this account closed?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Still Owe. Actions Taken

What actions have you taken to pay the lender?

[ Text ]

[3] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Still Owe. No Action Taken. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Court Name.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

[] Not Applicable (Text)

[2] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Court Address.

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

s

ZIP Code

[ Text ]

What is the court docket or order number associated with this repossession?

[ Text ]

[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer for Repossession in Past Five Years. Another Instance.

Do you have another instance where you had possessions or property repossessed in the past five years? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.)

[] Yes

[] No

*** End Of Branch ***

In the past five years, were you evicted from a rental property? (This applies whether you are the sole signer or a cosigner on the contract.)

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Type of Entity Evicting.

What type of entity evicted you from this rental property?

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Name of Entity Evicting.

What is the name of the company, government agency, or other entity that evicted you from the rental property? (Do not use acronyms or abbreviations.)

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Name of Individual who Evicted Individual if Evicted from Private Property.

Who evicted you from the property?

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

[2] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Selection of “Other” for Type of Eviction. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Additional Questions. Address.

What is the address of the property you were evicted from?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

When was your first missed rental payment?

[ mm/yyyy ]

[] Estimated

How many rental payments did you miss?

[ Text ]

[] Estimated

How much money do or did you owe (in U.S. dollars)?

[ Text ]

[] Estimated

Why did you stop making rental payments?

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Date and Status.

When were you evicted?

[ mm/yyyy ]

[] Estimated

Do you still owe money to the entity or private individual you named above?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Does Not Owe.

When did you satisfy this debt?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Still Owe.

What actions have you taken to pay this debt?

[ Text ]

[] None

[3] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Still Owe and No Action Taken. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Court Name.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

[] Not Applicable (Text)

[2] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Court Address.

What is this court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

What is the court docket or order number associated with this eviction?

[ Text ]

[] I Don't Know

[1] Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years. Another Instance.

Do you have another instance where you were evicted from a rental property in the past five years? (This applies whether you are the sole signer or a cosigner on the contract.)

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you had any of your wages, benefits, or assets seized? (Examples include wage garnishments, retirement benefit garnishments, or seizures of money from a bank account. Do not list foreclosures or repossessions you listed above.)

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years.

Which one was seized? (There will be an opportunity to input multiple entries.)

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Selection of “Other” for Type of Seizure. Explanation

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Additional Details.

Why were these wages, benefits, or assets seized?

[ Text ]

When were these wages, benefits, or assets seized?

[ mm/yyyy ]

[] Estimated

How much money do or did you owe (in U.S. dollars)?

[ Text ]

[] Estimated

Do you still owe money on this debt?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Does Not Owe. Date Resolved.

When did you resolve this debt?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Still Owe. Action Taken.

What actions have you taken to resolve this debt?

[ Text ]

[] None

[3] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Still Owe. No Action Taken. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Court Name.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

[] Not Applicable

[2] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Court Address.

What is this court's address? Street (include Apt #, Unit #, or Suite #, if applicable) ZIP Code	[ Text ] [ Text ]
City	[ Text ]

State or Territory

[ Dropdown ]

[1] Branch Auto Populate Affirmative Answer for Garnishments or Seizures of Wages, Benefits, Other in the Past Five Years. Docket/Order Number. Another Instance.

What is the court docket or order number associated with this asset seizure?

[ Text ]

[] I Don't Know

Do you have another instance where your wages, benefits, or assets were seized in the past five years? (Examples include wage garnishments, retirement benefit garnishments, or seizures of money from a bank account. Do not list foreclosures or repossessions you listed above.)

[] Yes

[] No

*** End Of Branch ***

In the past five years, have you failed to pay any non-federal taxes? (Examples of non-federal taxes include state and local taxes, property taxes, and personal property taxes.) Answer "No" if you 1) were not required to pay because you did not earn enough money, 2) did not owe money (you received or were entitled to a refund), or 3) were not required by law or ordinance to file or pay these taxes.)

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Type of Taxes.

What type of taxes did you fail to pay in the past five years?

[ Dropdown ]

[2] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Selection of “Other” from Dropdown Menu for Type of Taxes. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Details. Tax Year.

What tax year did you fail to pay?

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Details.

How much (in U.S. dollars) do you owe?

[ Text ]

[] I Don't Know

When was the filing date for these taxes?

[ mm/yyyy ]

[2] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Action Taken.

What actions have you taken to pay these taxes? (Select all that apply.)

[ Dropdown ]

[3] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Federal Taxes in the Past Five Years. Still Owe and No Action Taken. Explanation.

Please explain.

[ Text ]

[3] Branch Auto Populate Affirmative Answer for Failed to Pay Non-Fed Taxes and Not Paid In Full and Selection of “Other” on Action Taken.

Please explain.

[ Text ]

*** End Of Branch ***

In the past five years, were you disciplined for violating the terms of a government or employer travel card or credit card?

[] Yes

[] No

[1] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Name of Entity and Location.

What is the name of the government agency or the employer where you were disciplined? (Do not use acronyms or abbreviations in the name.)

[ Text ]

Is this government agency or employer located in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Location of Entity in the U.S. Address.

What is the address for this government agency or employer?

Street (include Apt #, Unit #, or Suite #, if applicable)	[ Text ]
City	[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Location of Entity in the U.S. And at a U.S. Military Installation. Name of Installation.

What is the name of the U.S. military installation?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Location of Entity Not in the U.S.

Where is this government agency or employer located?

City

[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Location of Entity Not in the U.S. but on Military/Diplomatic Installation. Name and Address.

What is the name of the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Type of Discipline.

What type of disciplinary action did you receive? (Select all that apply.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. No Actions Taken. Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Selection of “Other” Action Taken. Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Date.

When did you receive this disciplinary action?

[ mm/yyyy ]

[] Estimated

[1] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Additional Details.

How much money (in U.S. dollars) was involved?

[ Text ]

[] Estimated

What were the circumstances surrounding your travel or credit card violation? (Include whether you knowingly violated the terms of the travel or credit card, how many times you violated the terms, why you violated the terms, and any other details you think are important.)

[ Text ]

What actions have you taken to address this situation? (Select all that apply.)

[ Dropdown ]

[2] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Selection of “Other” Action Taken to Resolve. Explanation.

Please explain.

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Another Instance.

Do you have another instance in which you were disciplined for violating the terms of a government or employer travel card or credit card in the past five years?

[] Yes

[] No

*** End Of Branch ***

In the past five years, are you or were you more than 120 days past due on any debts? (Include only those not listed above) (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.)

[] No [] Yes

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for more than 120 Days Past Due in Past Five Years. Details.

What debt(s) are you or were you 120 days past due on? (Include the name of the company, government agency, or individual you owe or owed. If you have more than one debt, input one. There will be an opportunity to input multiple entries.)

[ Text ]

Why are you or were you past due on this debt?

[ Text ]

How much money do or did you owe (in U.S. dollars)?

[ Text ]

[] Estimated

When was your first missed payment?

[ mm/yyyy ]

[] Estimated

Are you still over 120 days past due on this debt?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for more than 120 Days Past Due in Past Five Years. Date Resolved.

When did you resolve this debt?

[ mm/yyyy ]

[] Estimated

[2] Branch Auto Populate Affirmative Answer for more than 120 Days Past Due in Past Five Years. Still Owe. Action Taken Explanation.

What actions have you taken to resolve this debt?

[ Text ]

[] None

[3] Branch Auto Populate Affirmative Answer for more than 120 Days Past Due in Past Five Years. Still Owe and No Action Taken.

Please explain.

[ Text ]

[1] Branch Auto Populate Affirmative Answer for more than 120 Days Past Due in Past Five Years. Loan or Account Information. Another Instance to Report.

What is the loan or account number associated with this debt?

[ Text ]

[] I Don't Know

Do you have another instance where you are or were in the past five years, over 120 days past due on a debt not previously listed? (This applies whether you are the sole debtor, a cosigner, or guarantor for the debt. A guarantor is an individual who is able and willing to take financial responsibility if the debtor or cosigner defaults on their financial obligation.)

[] Yes

[] No

*** End Of Branch ***

Are you currently using a credit counseling service, debt consolidation service, or other similar service to resolve any past due financial obligations?	[ Text ]	[] Yes	[] No
		[] Not Applicable (Text)

[1] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Name and Location of Service.

What is the name of this credit counseling service, debt consolidation service, or other similar service? (Do not use acronyms or abbreviations in the name.)

[ Text ]

[] Estimated

Is this service located in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Location in the U.S.

What is the address of this service?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

Is this a U.S. military installation?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Location in the U.S. and on Military Installation. Name.

What is the name of the U.S. military installation?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Location Not in the U.S.

Where is this service located?

City

[ Text ]

Country

[ Dropdown ]

Is this a U.S. military installation or U.S. diplomatic facility?

[] Yes

[] No

[3] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Location Not in the U.S. but on Military or Diplomatic Facility.

Is this a U.S. military installation or U.S. diplomatic facility?

[ Text ]

[] Not Applicable (Text)

What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility?

[ Text ]

[1] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Entity’s Phone Number.

What is the phone number for this service?

[Ctry|Num|Ext|Type]

[] [Day/Night/Both]

[1] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Services Effectiveness.

Has this credit counseling service, debt consolidation service, or other similar service been effective in helping you resolve your past due financial obligations?

[] Yes

[] No

[2] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Services Effectiveness. Explanation.

How?

[ Text ]

[2] Branch Auto Populate for Affirmative Answer for Currently Using Credit Counseling/Debt Consolidation Services to Resolve Any Past Due Obligations. Services Effectiveness. Reason.

Why?

[ Text ]

*** End Of Branch ***

Section 24 - Civil Court Actions

This section asks for information regarding any civil court actions you have been a party to in the past five years, as applicable. Information requested includes who were the parties involved, the circumstances surrounding the case, and the outcome.

For this section:

• Civil court actions are noncriminal lawsuits filed by a plaintiff against a defendant. Civil court actions may also be referred to as civil cases, civil proceedings, or civil suits. Please do not report divorce or non-criminal civil infractions (like traffic violations) under this section.

• A party means you were either a plaintiff or defendant to the lawsuit. A plaintiff is the person who is filing the lawsuit. The defendant is the person who is responding to the lawsuit. In some courts, a defendant is called a respondent.

In the past five years, were you a party to any civil court action?

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Details.

Were you the plaintiff or the defendant?

[] Plaintiff

[] Defendant

What is the name of the other party in this civil court action?

[2] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Names of Principal Parties. Details.

Last Name

[ Text ]

[] Letter(s) Only

First Name

[ Text ]

[] Letter(s) Only

Middle Name

[ Text ]

[] Letter(s) Only

[] No Middle Name

Suffix	[ Dropdown ]
		[] None

Is this person a plaintiff or defendant?

[] Plaintiff

[] Defendant

Do you have another party in this civil court action to report?

[] Yes

[] No

[1] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Court Name and Location.

What is the name of the court involved? (Do not use acronyms or abbreviations.)

[ Text ]

Is this court in the U.S.?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Court Location in the U.S.

What is the court's address?

Street (include Apt #, Unit #, or Suite #, if applicable)

[ Text ]

City

[ Text ]

State or Territory

[ Dropdown ]

ZIP Code

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Court Location Not in the U.S.

Where is this court located?

City

[ Text ]

Country

[ Dropdown ]

[1] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Details.

Describe in detail the nature of this civil court action. (Include what happened, where the event occurred, who was involved, what was the motivation, and any other details.)

[ Text ]

Is this civil court action closed?

[] Yes

[] No

[2] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Case Closed date and Outcome.

When was this civil court action closed?

[ mm/yyyy ]

[] Estimated

What was the outcome of this civil court case? (Select all that apply)

[ Dropdown ]

[3] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Case Outcome Selection of “Other” in Dropdown Menu. Explanation.

Please explain.

[ Text ]

[2] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Case Not Closed

When are you scheduled to go to court?

[ mm/yyyy ]

[] Estimated

[1] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Public Record.

Is this civil court action a matter of public record?			[] Yes	[] No
			[] I Don't Know

[1] Branch Auto Populate Affirmative Answer for Civil Court Actions in the Past Five Years. Another Instance.

Do you have another civil court action in which you were a party to in the past five years to report?

[] Yes

[] No

*** End Of Branch ***

123