Personnel Vetting Questionnaire

For Reference Only
This document is intended to be used in concert with the proposed information collection request (ICR)
titled Personnel Vetting Questionnaire (PVQ) 30-day notice. This document lists out all the dropdown
values within the new PVQ.

Throughout the Form
State Territory Values (Used for all addresses)
• Standardized State/Territory List
Country Values (Used for all addresses and country questions)
• Standardized Country List
Telephone Types Values (Selection option after each telephone number entered)
1. Day
2. Night
3. Both
4. Extension
5. International
6. DSN
7. I don't know.
Email Addresses Type Values (Used throughout the document for email address types)
1. Personal email
2. Work email
3. I don’t know
Federal Agency Values (Used throughout document )
• Standardized Federal Agency List

Section 01 – General Information (and throughout form for names)
Name Suffix Values
1. Jr.
2. Sr.
3. II
4. III
5. IV
6. V
7. VI
8. VII
9. VIII
10. IX
11. X
12. Other
13. None
1

Section 03 – U.S. Citizenship
Citizenship Values (Also used in Part B, Section 20 Citizenship for Spouse or Partner and Section 21,
Relatives.)
1. A U.S. citizen by birth in the U.S. or a U.S. territory.
2. A U.S. citizen by birth, born to U.S. parent(s), in a foreign country.
3. A naturalized U.S. citizen.
4. A derived U.S. citizen.
5. Not a U.S. citizen.
6. A U.S. national by birth in the U.S. or a U.S. territory.
7. A U.S. national by birth, born to U.S. parent(s), in a foreign country.
U.S. Citizen Born Abroad Document Values (Also used in Part B, Section 20 Spouse or Partner Born
Abroad and Section 21 Relatives.)
1. Form FS-240 (Consular Report of Birth Abroad)
2. Form DS-1350 (Certificate of Report of Birth)
3. Form FS-545 (Certificate of Birth Abroad)
4. Form N-560 or Form N-561 (Certificate of Citizenship)
5. Other
Residency Status Values (Also used in Part B, Section 20, Branch Auto Populate Spouse or Partner Not
U.S. Citizen and Part B, Section 21, Branch Auto Populate Relative Alive. Citizenship Status: Not a U.S.
Citizen. Resident of the U.S.)
1. Permanent Resident
2. Asylee/Refugee
3. Nonimmigrant
4. Temporary Protected Status (TPS)
5. Deferred Action for Childhood Arrivals (DACA)
6. Other
Document Used to Verify Legal Residency (Used in Part A, Section 3, Document Authorizing Legal
Residency in the U.S. Used in Part B, Section 20, Branch Auto Populate Spouse or Partner Other
Document Authorizing Residency in the U.S. Also used in Part B, Section 21 Branch Auto Populate
Relative not a U.S. citizen but authorized to be in the U.S. )
1. Form I-94 (Arrival/Departure Record)
2. U.S. Visa Card (nonimmigrant visa)
3. Form I-20 (Student Exchange Visitor Program (SEVP))
4. Form DS-2019 ("J" Exchange Visitor Status)
5. Other

2

Section 04 – Additional Citizenships and Foreign Passports
Travel Duration Values (Also used for travel length information in Part B, Continuation of Section 04 Additional Citizenships/Foreign Passports Questions, Branch Auto Populate for Affirmative Answer on
Use of Foreign Passport or Identity Card. Used for Travel. And Part B, Section 22, Branch Auto Populate
Affirmative Answer for Foreign Travel. Travel Summary Questions.)
1. Less than 24 hours
2. 1-7 days
3. 8-14 days
4. 15-30 days
5. Over 30 days
6. Many short trips
Travel Purpose Values (Used in Part B, Continuation of Section 04 - Additional Citizenships/Foreign
Passports Questions, Branch Auto Populate for Foreign Travel on Foreign Passport or Identity Card.
Purpose of Travel. Part B, Section 22, Branch Auto Populate Affirmative Answer for Foreign Travel.
Reason for Travel.)
1. Business or professional conference (This does not include U.S. Government business or military
assignments.)
2. Volunteer activity
3. Education
4. Tourism
5. Trade show, conference, or seminar (not associated with your profession)
6. Visit with family or friends
7. Other

Section 05 – Residences
Temporary Living Situation Address Values (Part A, Section 5, Branch Auto Populate for Temporary
Residence.)
1. Extended Travel
2. Business
3. School
4. Military Training
5. Military Deployment
6. Other

Section 06 – Education

School Type Values
• Part A, Section 6, Branch Auto Populate for Education in the Last Five Years.
• Part A, Section 6, Branch Auto Populate Degree Received Over Five Years Ago. Education,
Information of School Awarding Degree.
• Part B, Continuation of Section 6- Education, Branch Auto Populate for Affirmative Answer on
Foreign Education.
1. Vocational/Technical/Trade School
2. College/University/Military Academy
3. High School
4. Other
3

School Learning Experience Values
• Part A, Section 6, Branch Auto Populate Education Additional Questions.
• Part A, Section 6, Branch Auto Populate Education, Describe School Experience (in-person, not-in
person, combination).
• Part B, Continuation of Section 6- Education, Branch Auto Populate for Affirmative Answer on
Foreign Education.
1. In-person
2. Not in-person (for example, correspondence, online, extension, other similar distance learning
education)
3. Combination of in-person and not in-person
Degree Type Values (Part A, Section 6, Branch Auto Populate Education Yes to Degree or Diploma.
1. Associate’s degree
2. Bachelor’s degree
3. Master's degree
4. Doctoral degree
5. Professional degree (for example, MD, JD, DVM)
6. High School diploma
7. Other
Relationship School Values (Part A, Section 6, Branch Auto Populate Education Person to Verify.)
1. Instructor
2. Counselor
3. Friend
4. Schoolmate
5. Other

Section 07 – Employment Activities
Employment Activity Values (Part A, Section 7, Initial question)
1. U.S. Military or Uniformed Service (U.S. Army, Navy, Marine, Coast Guard, Air Force, Space
Force, USPHS, or NOAA)
2. Other Federal Employment
3. Federal Contractor
4. State Government Employment
5. Non-government Employment (do not include self-employment)
6. Self-employed
7. Unemployed

4

Military Uniform Service Branch Values (Part A, Section 7, Branch Auto Populate for Employment Type
U.S. Military. Part A, Section 9, Branch Auto Populate for Military Service.)
1. Air National Guard
2. Army National Guard
3. National Oceanic and Atmospheric Administration Commissioned Officer Corps
4. U.S. Air Force
5. U.S. Army
6. U.S. Coast Guard
7. U.S. Marine Corps
8. U.S. Navy
9. U.S. Public Health Service Commissioned Corps
10. U.S. Space Force
Military Uniform Service Status Values (Part A, Section 9, Branch Auto Populate for U.S. Military
Service, Duty Status.)
1.
2.
3.
4.
5.
6.

Active Duty
Active Reserve/Guard
Traditional Reservist/Guardsman
Inactive Reserves/Individual Ready Reserves
Retired Reserve
Other

Military Discipline Values (Part A, Section 7, Branch Auto Populate for Employment Type U.S. Military,
Yes to Disciplinary Action. Part A, Section 7, Branch Auto Populate for Federal Employment Outside Past
Five Years. Affirmative for Disciplinary Actions. Part A, Section 9 U.S. Military and Uniformed Service
Affirmative for Disciplinary Actions.)
1. Letter of Admonishment
2. Letter of Reprimand
3. Article 15 (of the UCMJ)
4. Court-martial
5. Other
Military Discipline Sentence Values (Part A, Section 7, Branch Auto Populate for Employment Type U.S.
Military, Yes to Disciplinary Action.)
1. Reduction in rank
2. Forfeiture of pay
3. Suspended from duty
4. Detention
5. Restrictions
6. Extra duties
7. Correctional Custody
8. Confinement
9. Other

5

Civilian Military Values (Part B, Employment Continuation, Branch Auto Populate Affirmative Answer to
Ever Served in Foreign Government. Additional Question)
1. Civilian
2. Military
Discipline Values
•

1.
2.
3.
4.
5.
6.
7.
8.

Part A, Section 7, Branch Auto Populate for Employment Type U.S. Military, Yes to
Disciplinary Action.
• Part A, Section 7, Branch Auto Populate for Employment Type “Other.” Affirmative
on Disciplinary Actions.
• Part A, Section 8, Branch Auto Populate for Federal Employment Outside Past Five
Years. Affirmative for Disciplinary Actions.
Written Warning
Official Counseling
Official Reprimand
Suspended
Demoted - Reduction in grade
Demoted - Reduction in pay
Removed from position, but not from employment
Other

Section 09 – U.S. Military and U.S. Uniformed Service
Military Discharge Type Values (Part A, Section 9, Branch Auto Populate for U.S. Military Service,
Discharge/Separation Type.)
1. Honorable Discharge
2. General Discharge Under Honorable Conditions (this is not an Honorable Discharge)
3. Other Than Honorable Discharge
4. Dismissal
5. Bad Conduct Discharge
6. Dishonorable Discharge
7. Other Type of Separation (Entry-Level Separation, Medical Separation, Separation for
Convenience of the Government)
Court Martial Type Values (Part A, Section 9, Branch Auto Populate for U.S. Military Service, Disciplinary
Action, Court Martial.)
1. Summary
2. Special
3. General

6

Criminal Outcome Values (Part A, Section 9, Branch Auto Populate for U.S. Military Service, Disciplinary
Action, Court Martial, Charges. Part A, Section 11, Branch Auto Populate for any Affirmative Answer to
Police Record. Charge, Outcome.)
1. Not guilty
2. Nolle Prosequi
3. Charge dismissed or disposed of
4. Charge dismissed or disposed of after a deferred adjudication or deferred judgment (not
applicable for military under the UCMJ)
5. Guilty
6. On trial
7. Awaiting trial
8. Other
Non-U.S. Government Service Values (Part B, Continuation of Section 7 - Employment, Branch Auto
Populate for Affirmative Answer to Ever Served in Foreign Government.)
1. Military or Armed Forces
2. Intelligence Service
3. Diplomatic Service
4. Security Service
5. Militia
6. Other Defense Force
7. Other Government Force
8. Other
Civilian Military Values (Part B, Continuation of Section 7, Branch Auto Populate for Affirmative Answer
to Ever Served in Foreign Government. Additional Questions.)
1. Civilian
2. Military member
Frequency Values (Used throughout form for frequency of contact values)
1. Daily
2. Weekly
3. Monthly
4. Quarterly
5. Annually
6. Other

Section 11 – Police Record
Charges Category Values
• Part A, Section 11, Branch Auto Populate for any Affirmative Answer to Police Record. Charge and
Type.
• Part B, Continuation of Section 11, Branch Auto Populate for Affirmative Answer to Any of the Police
Record Questions Above. Affirmative Answer Court Appearance . Charge.
• Part C, Section 29, Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S.
Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence.
Conviction Not Previously Reported on this Form. Details on Charge(s).
7

1.
2.
3.
4.
5.

Infraction or Violation
Summary offense
Misdemeanor offense
Felony offense
Other

Criminal Sentence Values
• Part A, Section 11, Branch Auto Populate for any Affirmative Answer to Police Record. Charge,
Outcome Guilty, Type of Sentence.
• Part A, Section 11, Branch Auto Populate for any Affirmative Answer to Police Record. Charge,
Outcome Dismissed.
• Part B, Continuation of Section 11, Branch Auto Populate for Affirmative Answer to Any of the
Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of
Guilty, Sentenced.
• Part B, Continuation of Section 11, Branch Auto Populate for Affirmative Answer to Any of the
Police Record Questions Above. Affirmative Answer Court Appearance. Outcome Selection of
Dismissed.
• Part C, Section 29, Branch Auto Populate for Affirmative Answer for Conviction of a Crime in a U.S.
Court Sentenced to Over One Year Imprisonment and Served at Least One Year of that Sentence.
Final Outcome of Conviction. Dates and Type of Sentence.
1. Fined
2. Community Service
3. Imprisonment
4. Probation
5. Counseling/Treatment/Training
6. Other
Domestic Violence Order Values (Part A, Section 11, Branch Auto Populate for Affirmative Answer
Orders against Individual. Protected Party.)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Spouse
Former spouse
Co-habitant
Former cohabitant
Person you were dating
Former person you were dating
Domestic partner
Former domestic partner
Parent
Child
Sibling
Grandparent
In-law
Other

8

Section 12 – Drug Activity
Drug Values
• Part A, Section 12, Branch Auto Populate for Affirmative Answer to Drug Use/Misused Controlled
Substance in the past Five Years. Type of Drug.
• Part A, Section 12, Branch Auto Populate for Affirmative Answer to Ordered to
Counseling/Treatment because of Illegal Drug Use or Misuse of Prescription Drugs in the Past Five
Years. Type of Controlled Substance.
• Part A, Section 12, Branch Auto Populate for Affirmative Answer for Drug Use, Possessed,
Purchased, etc.
• Part A, Section 12, Branch Auto Populate for Affirmative Answer to Voluntary Treatment because of
Illegal Drug Use or Misuse of Prescription Drugs in the Past Five Years. Type of Drug or Controlled
Substance.
1. Cocaine or crack cocaine (such as rock or freebase)
2. Stimulants (such as amphetamines, speed, crystal meth, or ecstasy)
3. Depressants (such as barbiturates, methaqualone, or tranquilizers)
4. Ketamine (such as special K or jet)
5. Narcotics (such as opium, morphine, codeine, or heroin)
6. Hallucinogenic (such as LSD, PCP, or mushrooms)
7. Steroids (such as the clear or juice)
8. Inhalants (such as toluene or amyl nitrate)
9. Other
Criminal Justice and/or Public Safety Job Values
• Part A, Section 12, Branch Auto Populate for Affirmative Answer to Drug Use/Misused Controlled
Substance in the past Five Years. Used While Employed in Criminal/Justice Position. Details.
• Part A, Section 12, Branch Auto Populate for Affirmative Answer to Misused Prescription Drugs in
Past Five Years. Used While Employed in Criminal/Justice Position. Details.
• Part A, Section 12, Branch Auto Populate for Affirmative Answer for Drug Use, Possessed Purchase,
etc., Criminal Justice/Public Safety Position Details.
•

Part A, Section 12, Branch Auto Populate for Affirmative Answer to Using/Misusing Controlled
Substance While in Criminal Justice/Public Safety Position. Additional Questions.

•

Part A, Section 13, Branch Auto Populate for Affirmative Answer to Marijuana/Cannabis Derivative
Use in the Last 90 Days. While in Criminal Justice/Public Safety Position. Type of Position.
Part A, Section 13, Branch Auto Populate for Affirmative Answer to Marijuana/Cannabis Derivative
Use While Employed in Criminal Justice/Public Safety Position Not Already listed. Dates, Frequency,
Circumstances. Another Instance to Report.
Part A, Section 13, Branch Auto Populate for Affirmative Answer to involved in Manufacture,
Cultivation, Trafficking, etc. in Past Five Years. While in a Criminal Justice/Public Safety Position.
Type of Position and Explanation.
1. Police/law enforcement officer
2. Parole/probation officer
3. 911 dispatcher
4. Correction officer
5. Lawyer
6. Court official
7. Firefighter
9

•
•

8.
9.
10.
11.

EMS
Medical and health services member
Emergency response team member
Other

Counseling Ordered By Values (Part A, Section 12, Branch Auto Populate for Affirmative Answer to
Ordered to Counseling/Treatment because of Illegal Drug Use or Misuse of Prescription Drugs in the Past
Five Years. Who Ordered. Part B, Section 19, Branch Auto Populate for Affirmative Answer on Ordered
Counseling or Treatment.)
1. Employer
2. Military Commander
3. Medical Professional
4. Mental Health Professional
5. Court Official/Judge
6. Other
Counseling Voluntary Values (Part A, Section 14, Branch Auto Populate for Affirmative Answer to
Voluntary Treatment because of Illegal Drug Use or Misuse of Prescription Drugs in the Past Five Years.
Who Recommended. Part A, Section 12, Branch Auto Populate for Affirmative Answer to Voluntary
Treatment because of Illegal Drug Use or Misuse of Prescription Drugs in the Past Five Years. Who
Recommended.)
1. Employer
2. Military Commander
3. Employee Assistance Program
4. Medical Professional
5. Mental Health Professional
6. Other
7. No

10

Section 14 – U.S. Personnel Vetting Investigations, Security Clearance,
and Federal Debarments.
Investigating Agency Values (Part A, Section 14, Branch Auto Populate for Personnel Vetting
Investigation. Agency. Part A, Section 14, Branch Auto Populate for Cleared, Agency that Granted
Clearance.)
1. Central Intelligence Agency (CIA)
2. DoD - Air Force Office of Special Investigations (AFOSI)
3. DoD - Defense Counterintelligence and Security Agency (DCSA)
4. DoD - Defense Intelligence Agency (DIA)
5. DoD - National Geospatial-Intelligence Agency (NGA)
6. DoD - National Reconnaissance Office (NRO)
7. DoD - National Security Agency (NSA)
8. DHS - Customs and Border Protection (CBP)
9. DHS – Federal Emergency Management Agency (FEMA)
10. DHS - Headquarters (DHS-HQ)
11. DHS - Immigration and Customs Enforcement (ICE)
12. DHS – Transportation Security Agency (TSA)
13. DHS – U.S. Coast Guard (USCG)
14. DHS – U.S. Customs and Immigration Service (USCIS)
15. DHS - U.S. Secret Service (USSS)
16. DOJ - Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)
17. DOJ - Federal Bureau of Investigation (FBI)
18. Department of State (DoS)
19. Treasury – Bureau of Engraving and Printing
20. Treasury – Bureau of Fiscal Services
21. Millennium Challenge Corporation
22. Office of Personnel Management (OPM)
23. Tennessee Valley Authority (TVA)
24. U.S. Agency for International Development (USAID)
25. U.S. Peace Corps (USPC)
26. U.S. Postal Inspection Service (USPIS)
27. Other
28. I don't know
Security Clearance Suspension Outcome Values (Part A, Section 14, Branch Auto Populate for Clearance
Suspended, Additional Details.)
1. Security clearance is still suspended
2. Security clearance was reinstated
3. Security clearance was revoked
4. Other

11

PIV Suspension Outcome Values (Part A, Section 14, Branch Auto Populate for PIV Suspended,
Additional Details.)
1. PIV Credential is still suspended
2. PIV Credential was reinstated/reissued
3. PIV Credential was revoked
4. Other

Section 15 – Federal Debt
Federal Debt Type Values (Part A, Section 15, Branch Auto Populate, Overdue On Federal Non-Tax
Debt.)
1. Student loan
2. Home mortgage loan
3. Over payment of benefits
4. Other
Federal Non-Tax Activity Values (Part A, Section 15, Branch Auto Populate, Overdue On Federal NonTax Debt, Actions Taken.)
1. I've increased my withholdings.
2. I'm on a payment plan.
3. My wages are being garnished.
4. I'm using a credit counseling service, debt consolidation service, or other similar service to
resolve this debt.
5. I paid this debt.
6. Other
7. None
Federal Tax Activity Values (Part A, Section 15, Branch Auto Populate, Failed To Pay Federal Taxes,
Actions Taken. Part B, Section 23, Branch Auto Populate Affirmative Answer for Failed to Pay NonFederal Taxes in the Past Five Years. Action Taken.)
1. I'm on an IRS short term payment plan (paying in 180 days or less).
2. I'm on an IRS long-term payment plan (installment agreement--I pay monthly).
3. I've increased my withholdings.
4. The IRS temporarily delayed collecting my taxes due to financial hardship.
5. My wages are being garnished.
6. I'm using a credit counseling service, debt consolidation service or other similar service to
resolve my tax debt.
7. Other
8. None

12

Section 16 – Information Technology Systems and Section 17 – Handling
Protected Information
Location of IT Systems / Handling Protected Info Incident Values
• Part A, Section 17, Branch Auto Populate, Improper IT Systems Access
• Part A, Section 17, Branch Auto Populate Illegally or without Proper Authorization, Modified,
Destroyed or Manipulated information on IT System Past Five Years. or Destroy. Dates and Location
• Part A, Section 17, Branch Auto Populate Illegally or Without Authorization Denied Access to
Information on IT System or Tried to in Past Five Years. Dates and Location.
• Part A, Section 17, Branch Auto Populate Illegally or Without Authorization Introduced,
Used, or Removed Hardware, Software, Media from IT System in Past Five Years. Date and
Location.
• Part A, Section 17, Branch Auto Populate Illegally or Without Proper Authorization Accessed or Tried
to Access Protected Information in Past Five Years. Date and Location.
• Part A, Section 17, Branch Auto Populate Non-Compliance with Rules or Regulations for
Safeguarding Protected Information in the Past Five Years. Dated and Location.
1. Home address
2. Work address
3. Other
Information Technology Systems Type Values
• Part A, Section 16, Branch Auto Populate, Improper IT Systems Access, Type of Information
Accessed.
• Part A, Section 16, Branch Auto Populate Illegally or without Proper Authorization, Modified,
Destroyed or Manipulated information on IT System Past Five Years. Change Or Destroy, Successful.
• Part A, Section 16, Branch Auto Populate Illegally or Without Authorization Denied Access to
Information on IT System or Tried to in Past Five Years. Successful.
1. Classified Information
2. Personally Identifiable Information
3. Proprietary Information
4. Other
Information Technology Systems Access / Handling Protected Information Frequency Values (Part A,
Section 16, and Section 17.)
1. 1
2. 2
3. 3-5
4. 6-10
5. Other
Information Technology Systems Access/Handling Protected Information Disciplinary Values
• Part A, Section 16, Branch Auto Populate, Improper IT Systems Access, Reason.
• Part A, Section 16, Branch Auto Populate Illegally or without Proper Authorization, Modified,
Destroyed or Manipulated information on IT System Past Five Years. Change Or Destroy, Reason
Question. Actions.
• Part A, Section 16, Branch Auto Populate Illegally or Without Authorization Denied Access to
13

•
•
•

Information on IT System or Tried to in Past Five Years. Reason and Actions.
Part A, Section 16, Branch Auto Populate Illegally or Without Authorization Introduced, Used, or
Removed Hardware, Software, Media from IT System in Past Five Years. Reason and Actions.
Part A, Section 17, Branch Auto Populate Illegally or Without Proper Authorization Accessed or Tried
to Access Protected Information in Past Five Years. Reason and Action.
Part A, Section 17, Branch Auto Populate Non-Compliance with Rules or Regulations for
Safeguarding Protected Information in the Past Five Years. Reason and Actions.
1. Workplace disciplinary or administrative actions.
2. Civil actions
3. Criminal actions
4. Other
5. No actions taken
6. Security Violation or Infraction

Section 20 – Relationship Status
Marital Relationship Values (Part B, Section 20 (within section))
1. Single (never in a civil marriage, civil union, domestic partnership, or common law marriage)
2. In a civil marriage, civil union, domestic partnership, or common law marriage
3. In a committed, spouse-like relationship
4. Legally separated
5. Annulled
6. Divorced/Dissolved
7. Widowed
8. Common/co-parent
Naturalized Citizenship Document Values (Part B, Section 20, Branch Auto Populate Spouse or Partner
Naturalized
U.S. Citizen. Part B, Section 21, Branch Auto Populate Relative. Alive. Citizenship Status: Naturalized.
Document Type.)
1. Form N-550 or Form N-570 (Certificate of Naturalization)
2. Form I-551 (Permanent Resident Card/Resident Alien Card)
3. Form I-551 (Machine Readable Immigrant Visa (MRIV))
4. Other
Derived Citizenship Document Values (Part B, Section 20, Branch Auto Populate Spouse or Partner
Other Derived Document. Part B, Section 21, Branch Auto Populate Relative Derived U.S. Citizenship
Documentation.)
1. Certificate of Citizenship (Form N-560 or Form N-561)
2. Permanent Resident Card/Resident Alien Card (Form I-551)
3. Machine Readable Immigrant Visa (MRIV)
4. Other
Non-U.S. Citizen Document Values (Part B, Section 20, Branch Auto Populate Spouse or Partner Other
Document Authorizing Being in the U.S. Part B, Section 21, Branch Auto Populate Relative Alive.
Citizenship Status: Not a U.S. Citizen. Resident of the U.S. Authorization Document Type.)
1. I-551 Permanent Resident
2. I-766 Employment Authorization
3. Machine Readable Immigrant Visa (MRIV)
14

4.
5.
6.
7.
8.

I-94 Arrival-Departure Record
U.S. Visa (Red foil number)
I-20 Certificate of Eligibility for Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility of Exchange Visitor-J1-Status
Other

Other Name Values
• Part A, Section 20, Branch Auto Populate for Affirmative Answer on Other Names Used by Spouse or
Partner.
• Part A, Section 21, Branch Auto Populate Relative. Alive. Other Names Details. Part C, Section 25,
Branch Auto Populate for Affirmative Answer on Contact with Foreign Nationals in Past 5 years Who
Meets One or More of Conditions Listed. Branch Auto Populate if the Foreign National Has Used
Other Names.
• Part C, Section 25, Branch Auto Populate for Affirmative Answer to Spouse or Partner Having
Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed. Other
Names Used by Foreign National.
1. Name prior to marriage
2. Former married name
3. Nickname
4. Alias
5. Former legal name
6. Other

Section 21 - Relatives
Relative Values (Part B, Section 21 within section.)
1. Parent
2. Stepparent
3. Foster parent
4. Child (including adopted/foster)
5. Stepchild
6. Sibling
7. Step Sibling
8. Half Sibling
9. Parent-in-law
10. Guardian
Contact Method Values (Part B, Section 21, Branch Auto Populate Relative Alive. Citizenship Status: Not
a U.S. Citizen. Contact with Non-U.S. Citizen Relative Information. Part C, Section 25, Branch Auto
Populate for Affirmative Answer on Contact with Foreign National in the Past Five Years Who Meets One
or More of Conditions Listed. Additional Question on Span and Method of Contact.)
1. In-person
2. Telephone
3. Electronic means (for example, email, texting, chat rooms)
4. Written correspondence
5. Other
6. None
15

Section 23 – Financial Record
Bankruptcy Chapter Values (Part B, Section 23, Branch Auto Populate Affirmative Answer for
Bankruptcy in Past Five Years.)
1. Chapter 7 (Liquidation)
2. Chapter 11 (Reorganization)
3. Chapter 12 (Adjustment of Debts of a Family Farmer with Regular Annual Income)
4. Chapter 13 (Adjustment of Debts of an Individual with Regular Annual Income)
5. Chapter 15 (Ancillary and Other Cross-Border Cases)
Lien, Foreclosure, Evicted By Values
• Part B, Section 23, Branch Auto Populate Affirmative Answer for Lien in Past Five Years. Entity
Placing Lien.
• Part B, Section 23, Branch Auto Populate for Affirmative Answer for Property Foreclosure in Past
Five Years. Entity Type.
• Part B, Section 23, Branch Auto Populate for Affirmative Answer for Eviction in the Past Five Years.
Type of Entity Evicting.
1. Company
2. Government Agency
3. Individual
4. Other
Lien Property Type Values (Part B, Section 23, Branch Auto Populate Affirmative Answer for Lien in Past
Five Years. Property Type.)
1. Home (primary residence)
2. Vehicle
3. Boat/Plane
4. Real estate, land, property (other than your primary residence)
5. Jewelry
6. All of my property
7. You (a general lien against you as an individual)
8. Other personal property
Lien Reason Values (Part B, Section 23, Branch Auto Populate Affirmative Answer for Lien in Past Five
Years. Reason for Lien.)
1. Fulfill a home loan agreement (mortgage lien)
2. Fulfill an auto loan agreement (auto lien)
3. Pay a civil judgment (judgment lien)
4. Pay Federal taxes (tax lien)
5. Pay state taxes (tax lien)
6. Pay local taxes (tax lien)
7. Pay child support
8. Pay alimony
9. Pay for medical services after receiving a personal injury award
10. Pay a credit card company
11. Pay attorney fees
12. Pay condominium or homeowner's association fees
13. Pay a mechanic, laborer, or material provider (i.e., contractor's lien, mechanic's lien,
16

14.
15.
16.
17.
18.

construction lien)
Pay an employee's salary
Pay for jewelry
Pay for storage unit
Pay for parking garage
Other

Foreclosed Property Type Values (Part B, Section 23, Branch Auto Populate Affirmative Answer for
Foreclosure in the Past Five Years. Type of Property.)
1. Primary residence
2. Secondary residence
3. Residence that I cosigned for or was guarantor for
4. Plot of land
5. Rental property
6. Commercial property
7. Other
Repossessed Property Type Values (Part B, Section 23, Branch Auto Populate for Affirmative Answer for
Repossession in Past Five Years. Name of Lender. Type of Property.)
1. Vehicle (automobile, motorcycle, recreational vehicle)
2. Rent-to-own items (e.g., appliances, electronics, furniture, jewelry, etc.)
3. Other personal property
Items Seized Values (Part B, Section 23, Branch Auto Populate Affirmative Answer for Garnishments or
Seizures of Wages, Benefits, Other in the Past Five Years.)
1. Wages
2. Benefits
3. Other assets
Tax Type Values (Part B, Section 23, Branch Auto Populate Affirmative Answer Failed to Pay Non-Federal
Taxes in Past Five Years, Type of Taxes)
1. State taxes
2. Property tax (for example, real estate property)
3. Personal property tax (for example, for a car or boat)
4. Other
Non-Federal Tax Activity Values (Part B, Section 23, Branch Auto Populate Affirmative Answer for Failed
to Pay Non-Federal Taxes in the Past Five Years. Action Taken.)
1. I'm on a payment plan.
2. My wages are being garnished.
3. I'm using a credit counseling service, debt consolidation service, or other similar service to help
resolve my debt.
4. Other
5. None
Travel Card Disciplinary Values (Part B, Section 23, Branch Auto Populate for Affirmative Answer for
Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Type of
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Discipline.)
1. Travel/credit card withdrawn
2. Additional training or counseling
3. Verbal reprimand/admonishment/warning
4. Written reprimand/admonishment/counseling/warning
5. Temporary Pay Cut
6. Wage Garnishment
7. Suspended
8. Demoted
9. Terminated/Fired/Dismissed/Discharged (military)
10. Criminal action
11. UCMJ action
12. Other
Travel Card Activity Values (Part B, Section 23, Branch Auto Populate for Affirmative Answer for
Disciplined for Violating Terms of Government or Employer Credit Card Use in Past Five Years. Additional
Details)
1. I paid all unauthorized expenses.
2. I am successfully meeting the terms of a payment plan.
3. I have my pay garnished.
4. I'm using a credit counseling service, debt consolidation service, or other similar service to
resolve this financial obligation.
5. I completed additional training or counseling.
6. I'm using my agency's or employer's Employee Assistance Program (EAP).
7. Other
8. None

Section 24 – Civil Court Actions
Civil Court Outcome Values (Part B, Section 24, Branch Auto Populate Affirmative Answer for Civil Court
Actions in the Past Five Years. Case Closed date and Outcome.)
1. I was awarded damages
2. I was awarded restitution
3. I was awarded other remedies
4. I had to pay damages
5. I had to make restitution
6. I had to do other remedies
7. Other

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Section 25 – Foreign Contacts
Relationship Values
• Part C, Section 25, Branch Auto Populate for Affirmative Answer on Contact with Foreign National in
the Past Five Years Who Meets One or More of Conditions Listed. Type of Relationship with Foreign
National.
• Part C, Section 25, Branch Auto Populate for Affirmative Answer to Spouse or Partner Having
Contact with Foreign National that May Influence or Obligate Individual, Not Previously Listed.
Spouse’s Relationship with Foreign National Question.
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual Controlling Foreign
Financial Interest of Others. Name and Relationship.
• Part C, Section 27, Branch Auto Populate for Affirmative Answer to Business Venture with Foreign
National in the Past Five Years Not Previously Reported. Foreign National Country of Citizenship and
Type of Relationship.
1. Friend
2. Schoolmate
3. Neighbor
4. Work Associate
5. Landlord
6. Other
Foreign National Work Values (Part C, Section 25, Branch Auto Populate for Affirmative Answer on
Contact with Foreign National in the Past Five Years Who Meets One or More of Conditions Listed.
Foreign Government Affiliation Question. Part C, Section 25, Branch Auto Populate for Affirmative
Answer to Spouse or Partner Having Contact with Foreign National that May Influence or Obligate
Individual, Not Previously Listed. Association Question.)
1. Military or Armed Forces
2. Security Service
3. Intelligence Service
4. Other Government Agency
5. Defense Industry
6. Foreign Movement (such as a social, political, or religious movement)
7. They are not associated with any of the above.

Section 26 – Foreign Financial Interests and Foreign Benefits
Family with Foreign Interest Values
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like,
or Dependent Child Owning Foreign Financial Interest in Past Five Years.
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like,
or Dependent Child Expects Future Foreign Financial Interest. Who is Expected to Own.
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like,
or Dependent Child Receiving Benefits from a Foreign Country in the Past Five Years. Who Receives
the Benefits.
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Future Benefits.
1. Myself
2. Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or
common law marriage
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3. Person with whom you're in a committed, spouse-like relationship
4. Dependent children
Co-Owner of Foreign Financial Interest (Part C, Section 26, Branch Auto Populate for Affirmative Answer
for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five
Years. Identity of Co-Owner. Part C, Section 26, Branch Auto Populate for Affirmative Answer for
Individual, Spouse, Spouse-Like, or Dependent Child Owning Foreign Financial Interest in Past Five Years.
Selection of Controlled by Another Person. Relationship of Person with Co-Owner)
1. Yourself
2. Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or
common law marriage
3. Person with whom you're in a committed or spouse-like relationship
4. Dependent children
5. Other relative
6. Friend
7. Business Associate
8. Other
9. Common/co-parent
Foreign Financial Interest Values
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-like,
or Dependent.
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Foreign Financial Interest
• Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual, Spouse, Spouse-Like,
or Dependent Child Expects Future Foreign Financial Interest. Type of Foreign Financial Interest.
1. Stocks
2. Bonds
3. Ownership of corporate entities
4. Corporate interests held in specific geographical or economic sectors
5. Exchange traded funds (ETFs) held in specific geographical or economic sectors
6. Real estate in a foreign country
7. Other Property (non-real estate)
8. Investments
9. Bank Account
10. Other (Do not list financial interests in companies or diversified mutual funds or diversified ETFs
that are publicly traded on a U.S. exchange.)
Real Estate Type Values (Part C, Section 26, Branch Auto Populate for Affirmative Answer for Individual,
Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years. Foreign
Financial Interest is Real Estate. Type of Real Estate.)
1. Home
2. Business
3. Land
4. Other

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How Acquired Interest Values (Part C, Section 26, Branch Auto Populate for Affirmative Answer for
Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years.
Foreign Financial Interest is Real Estate. Acquisition Details. Part C, Section 26, Branch Auto Populate for
Affirmative Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial
Interest in Past Five Years. Acquisition Details.)
1. Bought it
2. It was a gift
3. Inherited it
4. Other
How Relinquished Interest Values (Part C, Section 26, Branch Auto Populate for Affirmative Answer for
Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past Five Years.
Value when Sold or Relinquished.)
1. Sold it
2. Lost it
3. Gave it away
4. Other
Foreign Financial Interest Controller Values (Part C, Section 26, Branch Auto Populate for Affirmative
Answer for Individual, Spouse, Spouse-like, or Dependent Child Owning Foreign Financial Interest in Past
Five Years. Anyone Else Controls the Foreign Financial Interest.)
1. Company or organization controlled
2. Another person controlled (other than the owner or co-owner)
3. No one controlled this foreign financial interest on the owner or co-owner's behalf
4. Other
Foreign Benefit Type Values (Part C, Section 26, Branch Auto Populate for Affirmative Answer for
Individual, Spouse, Spouse-like, or Dependent Child Receiving Benefits from a Foreign Country in Past
Five Years.)
1. Educational
2. Medical
3. Retirement
4. Social Welfare
5. Other

Section 27 – Foreign Business Affairs and Foreign Government Activities
Immediate Family Values (Part C, Section 27, Branch Auto Populate for Affirmative Answer to Individual
or Family Members Being Asked by a Foreign Government for Advice or to be Consultant in Past Five
Years. Whom. Part C, Section 27, Branch Auto Populate for Affirmative Answer for Individual or
Immediate Family Member Having Contact with Foreign Government Agency or Representative in the
Past Five Years. Identify Individual with Contact.)
1. Myself
2. Spouse or legally recognized partner from a civil marriage, civil union, domestic partnership, or
common law marriage
3. Person with whom you're in a committed, spouse-like relationship
4. Parent
5. Stepparent
6. Child (including adopted/foster)
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7.
8.
9.
10.
11.
12.

Stepchild
Sibling
Stepsibling
Half-sibling
Parent-in-law
Guardian

Business with Foreign National Values (Part C, Section 27, Branch Auto Populate for Affirmative Answer
to Business Venture with Foreign National in the Past Five Years Not Previously Reported. Details of
Business Venture with Foreign National.)
1. I owned the business
2. I co-owned the business
3. I was a business consultant
4. I provided financial support
5. Other
Foreign Agency Values (Part C, Section 27, Branch Auto Populate for Affirmative Answer for Individual
or Immediate Family Member Having Contact with Foreign Government Agency or Representative in the
Past Five Years. Country and Type of Foreign Government Entity.)
1. Military or Armed Forces
2. Intelligence Service
3. Security Service
4. Diplomatic Service
5. Embassy
6. Consulate
7. Other
8. I don't know
Sponsor Foreign National Reason Values (Part C, Section 27, Branch Auto Populate for Affirmative
Answer for Sponsored Foreign National to the U.S. in Past Five Years. Reason for Sponsoring.
1. So they could attend school in the U.S.)
2. So they could work in the U.S.
3. So they could pursue permanent U.S. residency
4. Other

Section 29 – Criminal Convictions Resulting in Sentences Over One Year
Criminal Outcome Sentences Over One Year Values (Part C, Section 29, Branch Auto Populate for
Affirmative Answer to convicted of crime in U.S. Court sentenced to over one year imprisonment, served
at least one year of sentence.)
1. Not guilty
2. Nolle Prosequi
3. Charge dismissed or disposed of
4. Guilty
5. Other

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