Questionnaire For Public Trust Positions: Authority To Request This Information

Standard Form 85P Form approved:
Revised December 2017 QUESTIONNAIRE FOR OMB No. 3206 0258

U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736 PUBLIC TRUST POSITIONS
Follow instructions completely or your form will be unable to be processed. If Authority to Request this Information
you have any questions, contact the office that provided you the form.
Depending upon the purpose of your investigation, the U.S. Government is
All questions on this form must be answered completely and truthfully in authorized to ask for this information under Executive Orders, 13764, 10577,
order that the Government may make the determinations described below on 13467, and 13488; sections 3301, 3302, 7301, and 9101 of title 5, United
a complete record. Penalties for inaccurate or false statements are discussed States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal
below. If you are a current civilian employee of the federal government: Regulations (CFR), and Federal information processing standards.
failure to answer any questions completely and truthfully could result in an
adverse personnel action against you, including loss of employment; with Your Social Security Number (SSN) is needed to identify records unique to
respect to Sections 21, 25, and 27, however, neither your truthful responses you. Although disclosure of your SSN is not mandatory, failure to disclose
nor information derived from those responses will be used as evidence your SSN may prevent or delay the processing of your background
against you in a subsequent criminal proceeding. investigation. The authority for soliciting and verifying your SSN is Executive
Order 9397, as amended by EO 13478.
Note: If you complete the SF 85P, an Authorization for Release of Medical
Information Pursuant to the Health Insurance Portability and Accountability Your spouse's SSN is needed solely to allow the investigative service
Act (HIPAA) will be provided to you only in the event information arises in an provider to make inquiries regarding whether there is relevant conduct on
investigation that requires further inquiry for resolution, and only to resolve your part as a result of your relationship with your spouse. Your spouse is not
such issues. This release authorizes an investigator to ask your health subject of the investigation.
practitioner(s) only the questions specified on the release concerning mental
health consultations of which the practitioner might be aware. If you are
completing the SF 85P with the supplemental SF 85P-S, this release will be The Investigative Process
provided to you if you respond "yes" to the question regarding Your Medical Background investigations for public trust positions are conducted to gather
Record. You may also be asked to complete a specific release if more information to determine whether you are reliable, trustworthy, of good
detailed information is needed from your provider. conduct and character, and loyal to the U.S. The information that you provide
on this form and your Declaration for Federal Employment (OF 306) may be
confirmed during the investigation. The investigation may extend beyond the
Purpose of this Form time covered by this form, when necessary to resolve issues. Your current
This form will be used by the United States (U.S.) Government in conducting employer may be contacted as part of the investigation, although you may
background investigations and reinvestigations of persons under have previously indicated on applications or other forms that you do not want
consideration for, or retention of, public trust positions as defined in 5 CFR your current employer to be contacted. If you have a security freeze on your
731. This form may also be used by agencies in determining whether a consumer or credit report file, then we may not be able to complete your
subject performing work for, or on behalf of, the Government under a contract investigation, which can adversely affect your eligibility for a public trust
should be deemed eligible for logical or physical access when duties to be position or your ability to obtain Federal or contract employment. To avoid
performed by an employee of a contractor are equivalent to the duties such delays, you must request that the consumer reporting agencies lift the
performed by an employee in a public trust position. For applicants, this form freeze in these instances.
is to be used only after a conditional offer of employment has been made.
In addition to the questions on this form, inquiry also is made about your
This form is not to be used for National Security sensitive positions.
adherence to security requirements your honesty and integrity, falsification,
Providing this information is voluntary. If you do not provide each item of misrepresentation, and any other behavior, activities, or associations that
requested information, however, we will not be able to complete your tend to demonstrate a person is not reliable, trustworthy, or loyal.
investigation, which will adversely affect your eligibility for a public trust
After a suitability /fitness determination is made, you may also be subject to
position or your ability to obtain or retain Federal or contract employment, or
continuous vetting which may include periodic reinvestigations to ensure your
logical or physical access. It is imperative that the information provided be
continuing suitability for employment.
true and accurate, to the best of your knowledge. Any information that you
provide is evaluated on the basis of its currency, seriousness, relevance to
the position and duties, and consistency with all other information about you. Your Personal Interview
Withholding, misrepresenting, or falsifying information may affect your
eligibility for a public trust position, or your ability to obtain or retain Federal or Some investigations will include an interview with you as a routine part of the
contract employment. In addition, withholding, misrepresenting, or falsifying investigative process. The investigator may ask you to explain your answers
information may affect your eligibility for physical and logical access to to any question on this form. This provides you the opportunity to update,
federally controlled facilities or information systems. Withholding, clarify, and explain information on your form more completely, which often
misrepresenting, or falsifying information may also negatively affect your assists in completing your investigation. It is imperative that the interview be
employment prospects and job status, and the potential consequences conducted as soon as possible after you are contacted. Postponements will
include, but are not limited to, removal, debarment from Federal service, or delay the processing of your investigation, and declining to be interviewed
prosecution. may result in your investigation being delayed or canceled.
This form is a permanent document that may be used as the basis for future For the interview, you will be required to provide photo identification, such as
investigations, suitability or fitness for Federal employment, fitness for a valid state driver's license. You may be required to provide other documents
contract employment, or eligibility for physical and logical access to federally to verify your identity, as instructed by your investigator. These documents
controlled facilities or information systems. Your responses to this form may may include certification of any legal name change, Social Security card,
be compared with your responses to previous SF 85P questionnaires. passport, and/or your birth certificate. You may also be asked to provide
documents regarding information that you provide on this form, or about other
The investigation conducted on the basis of information provided on this form matters requiring specific attention. These matters include (a) alien
may be selected for studies and analyses in support of evaluating and registration or naturalization documents; (b) delinquent loans or taxes,
improving the effectiveness and efficiency of the investigative and bankruptcies, judgments, liens, or other financial obligations; (c) agreements
adjudicative methodologies. All study results released to the general public involving child custody or support, alimony, or property settlements; (d)
will delete personal identifiers such as name, social security number, and date arrests, convictions, probation, and/or parole; or (e) other matters described
and place of birth. in court records.
Page 1
Instructions for Completing this Form Office of Personnel Management (OPM) Routine Uses
1. Follow the instructions provided to you by the office that gave you this form The Privacy Act routine uses of agencies conducting or requesting
and any other clarifying instructions, provided by that office, to assist you investigations, or with authorized custody over your investigative information,
with completion of this form. You must sign and date, in ink, the original commonly include some or all of the following:
and each copy you submit. You should retain a copy of the completed a.
To designated officers and employees of agencies, offices, and other
form for your records.
establishments in the executive, legislative, and judicial branches of the
2. All questions on this form must be answered. If no response is necessary Federal Government or the Government of the District of Columbia having
or applicable, indicate this on the form by checking the associated "Not a need to investigate, evaluate, or make a determination regarding loyalty
Applicable" box, unless otherwise noted. to the United States; qualifications, suitability, or fitness for Government
employment or military service; eligibility for logical or physical access to
3. Do not abbreviate the names of cities or foreign countries. Whenever you federally-controlled facilities or information systems;eligibility for access to
are asked to supply a country name, you may select the country name by classified information or to hold a sensitive position; qualifications or
using the country drop down feature. fitness to perform work for or on behalf of the Government under contract,
4. When entering a U.S. address or location, select the state or territory from grant, or other agreement; or access to restricted areas.
the "States" drop down list that will be provided. For locations outside of
the U.S. and its territories, select the country in the "Country" drop down b. To an element of the U.S. Intelligence Community as identified in
list and leave the "State" field blank. E.O.12333, as amended, for use in intelligence activities for the purpose of
protecting United States national security interests.
5. The 5-digit postal Zip Codes are required to process your investigation
more rapidly. Refer to an automated system approved by the U.S. Postal c. To any source from which information is requested in the course of an
Service to assist you with Zip Codes. investigation, to the extent necessary to identify the individual, inform the
source of the nature and purpose of the investigation, and to identify the
6. For telephone numbers in the U.S., ensure that the area code is included. type of information requested.
7. All dates provided in this form must be in Month/Day/ Year or Month/Year d. To the appropriate Federal, state, local, tribal, foreign, or other public
format. Use numbers (01-12) to indicate months. For example, July authority responsible for investigating, prosecuting, enforcing, or
29,1968, should be written as 07/29/1968. If you are unable to report an implementing a statute, rule, regulation, or order where OPM becomes
exact date, approximate or estimate the date to the best of your ability,and aware of an indication of a violation or potential violation of civil or criminal
indicate this by checking the “Estimate” box. law or regulation.
e. To an agency, office, or other establishment in the executive, legislative,or

Final Determination on Your Suitability judicial branches of the Federal Government in response to its request,in
connection with its current employee’s, contractor employee’s, or military
Final determination on your suitability for a public trust position is the
member’s retention; loyalty; qualifications, suitability, or fitness for
responsibility of the Office of Personnel Management or the Federal agency
employment; eligibility for logical or physical access to federally-controlled
that requested your investigation. You may be provided the opportunity to
facilities or information systems; eligibility for access to classified
explain, refute, or clarify any information before a final decision is made. The
information or to hold a sensitive position; qualifications or fitness to
United States Government does not discriminate on the basis of prohibited
perform work for or on behalf of the Government under contract, grant, or
categories, including but not limited to race, color, religion, sex (including
other agreement; or access to restricted areas.
pregnancy and gender identity), national origin, disability, or sexual orientation
when making determinations of suitability for a public trust position. f. To provide information to a congressional office from the record of an
individual in response to an inquiry from the congressional office made at
the request of that individual. However, the investigative file, or parts
Penalties for Inaccurate or False Statements thereof, will only be released to a congressional office if OPM receives a
notarized authorization or signed statement under 28 U.S.C. 1746 from
The U.S. Criminal Code (title 18, section 1001) provides that knowingly
the subject of the investigation.
falsifying or concealing a material fact is a felony which may result in fines
and/or up to five (5) years imprisonment. In addition, Federal agencies g. To disclose information to contractors, grantees, or volunteers performing
generally fire, or disqualify individuals who have materially and deliberately or working on a contract, service, grant, cooperative agreement, or job for
falsified these forms, and this remains a part of the permanent record for the Federal Government.
future placements. Your prospects of placement are better if you answer all
questions truthfully and completely. You will have adequate opportunity to h. For agencies that use adjudicative support services of another agency, at
explain any information you provide on this form and to make your comments the request of the original agency, the results will be furnished to the
part of the record. agency providing the adjudicative support.
i. To provide criminal history record information to the FBI, to help ensure

Disclosure Information the accuracy and completeness of FBI and OPM records.
The information you provide is for the purpose of investigating you for a
position, and the information will be protected from unauthorized disclosure. j. To appropriate agencies, entities, and persons when (1) OPM suspects or
The collection, maintenance, and disclosure of background investigative has confirmed that there has been a breach of the system of records; (2)
information are governed by the Privacy Act. The agency that requested the OPM has determined that as a result of the suspected or confirmed breach
investigation and the agency that conducted the investigation have published there is a risk of harm to individuals, the agency (including its information
notices in the Federal Register describing the systems of records in which systems, programs and operations), the Federal Government,or national
your records will be maintained. The information you provide on this form, security; and (3) the disclosure made to such agencies,entities, and
and information collected during an investigation, may be disclosed without persons is reasonably necessary to assist in connection with OPM’s efforts
your consent by an agency maintaining the information in a system of records to respond to the suspected or confirmed breach or to prevent, minimize,
as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list or remedy such harm.
of which are published by the agency in the Federal Register. The office that
gave you this form will provide you a copy of its routine uses.
Page 2
k. To another Federal agency or Federal entity, when OPM determines that u. To appropriately cleared individuals in Federal agencies, to determine
information from this system of records is reasonably necessary to assist whether information obtained in the course of processing the background
the recipient agency or entity in (1) responding to a suspected or investigation is or should be classified.
confirmed breach or (2) preventing, minimizing, or remedying the risk of
harm to individuals, the agency (including its information v. To the Office of the Director of National Intelligence for inclusion in its
systems,programs and operations), the Federal Government, or national Scattered Castles system in order to facilitate reciprocity of background
security,resulting from a suspected or confirmed breach. investigations and security clearances within the intelligence community
l. To disclose information to another Federal agency, to a court, or a party or assist agencies in obtaining information required by the Federal
in litigation before a court or in an administrative proceeding being Investigative Standards.
conducted by a Federal agency, when the Government is a party to the
judicial or administrative proceeding. In those cases where the w. To the Director of National Intelligence, or assignee, such information as
Government is not a party to the proceeding, records may be disclosed if may be requested and relevant to implement the responsibilities of the
a subpoena has been signed by a judge. Security Executive Agent for personnel security, and pertinent personnel
security research and oversight, consistent with law or executive order.
m. To disclose information to the National Archives and Records
Administration for use in records management inspections. x. To Executive Branch Agency insider threat, counterintelligence, and
counter terrorism officials to fulfill their responsibilities under applicable
n. To disclose information to the Department of Justice, or in a proceeding Federal law and policy, including but not limited to E.O. 12333, 13587and
before a court, adjudicative body, or other administrative body before the National Insider Threat Policy and Minimum Standards.
which OPM is authorized to appear, when:
y. To the appropriate Federal, State, local, tribal, foreign, or other public
(1) OPM, or any component thereof; or authority in the event of a natural or man made disaster. The record will
(2) Any employee of OPM in his or her official capacity; or be used to provide leads to assist in locating missing subjects or assist in
determining the health and safety of the subject. The record will also be
(3) Any employee of OPM in his or her individual capacity where used to assist in identifying victims and locating any surviving next of kin.
the Department of Justice or OPM has agreed to represent the
employee; or z. To Federal, State, and local government agencies, if necessary, to obtain
(4) The United States, when OPM determines that litigation is likely information from them which will assist OPM in its responsibilities as the
to affect OPM or any of its components; is a party to litigation or authorized Investigation Service Provider in conducting studies and
has an interest in such litigation, and the use of such records analyses in support of evaluating and improving the effectiveness and
by the Department of Justice or OPM is deemed by OPM to be efficiency of the background investigation methodologies.
relevant and necessary to the litigation, provided, however, that
the disclosure is compatible with the purpose for which records aa. To an agency, office, or other establishment in the executive,
were collected. legislative,or judicial branches of the Federal Government in response to
its request, in connection with the classifying of jobs, the letting of a
o. For the Merit Systems Protection Board--To disclose information to contract, or the issuance of a license, grant, or other benefit by the
officials of the Merit Systems Protection Board or the Office of the Special requesting agency, to the extent that the information is relevant and
Counsel, when requested in connection with appeals, special studies of necessary to the requesting agency’s decision on the matter.
the civil service and other merit systems, review of OPM rules and
regulations, investigations of alleged or possible prohibited personnel
practices, and such other functions, e.g., as promulgated in 5U.S.C. 1205 Public Burden Information
and 1206, or as may be authorized by law.
Public burden reporting for this collection of information is estimated
p. To disclose information to an agency Equal Employment toaverage155minutesperresponse,including time for reviewing instructions,
Opportunity(EEO) office or to the Equal Employment Opportunity searching existing data sources, gathering and maintaining the data needed,
Commission when requested in connection with investigations into and completing and reviewing the collection of information. Send comments
alleged or possible discrimination practices in the Federal sector, or in the regarding the burden estimate or any other aspect of this collection of
processing of a Federal-sector-sector EEO complaint. information, including suggestions for reducing this burden, to OPM Forms
Officer, U.S. Office of Personnel Management, Attn: OMB Number 3206-0258,
q. To disclose information to the Federal Labor Relations Authority or its 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number,
General Counsel when requested in connection with investigations of 3206-0258, is currently valid. OPM may not collect this information, and you
allegations of unfair labor practices or matters before the Federal Service are not required to respond, unless this number is displayed.
Impasses Panel.
r. To another Federal agency’s Office of Inspector General when OPM

becomes aware of an indication of misconduct or fraud during the
applicant’s submission of the standard forms.
s. To another Federal agency’s Office of Inspector General in connection

with its inspection or audit activity of the investigative or adjudicative
processes and procedures of its agency as authorized by the Inspector
General Act of 1978, as amended, exclusive of requests for civil or
criminal law enforcement activities.
t. To a Federal agency or state unemployment compensation office upon its

request in order to adjudicate a claim for unemployment compensation
benefits when the claim for benefits is made as the result of a
qualifications, suitability, fitness, security, identity credential, or access
determination.
Page 3
LOCATION CODES
Alabama AL Hawaii HI Massachusetts MA New Mexico NM South Dakota SD
Alaska AK Idaho ID Michigan MI New York NY Tennessee TN
Arizona AZ Illinois IL Minnesota MN North Carolina NC Texas TX
Arkansas AR Indiana IN Mississippi MS North Dakota ND Utah UT
California CA Iowa IA Missouri MO Ohio OH Vermont VT
Colorado CO Kansas KS Montana MT Oklahoma OK Virginia VA
Connecticut CT Kentucky KY Nebraska NE Oregon OR Washington WA
Delaware DE Louisiana LA Nevada NV Pennsylvania PA West Virginia WV
District of Columbia DC Maine ME New Hampshire NH Rhode Island RI Wisconsin WI
Florida FL Maryland MD New Jersey NJ South Carolina SC Wyoming WY
Georgia GA
American Samoa AS Johnson Atoll JQ Midway Islands MQ Palmyra Atoll LQ Wake Island WQ
Baker Island FQ Kingman Reef KQ Navassa Island BQ Puerto Rico PR APO/FPO America AA
Guam GU Marshall Islands MH Northern Mariana Islands MP Virgin Islands, United VI APO/FPO Europe AE
Howland Island HQ Micronesia, Federated FM Palau PW States APO/FPO Pacific AP
Jarvis Island DQ States
AGENCY USE BLOCK "AUB"

Investigating agency user only Codes: (FIPC CODES) Case Number:
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED
IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE
DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
A Type of investigation B Extra coverage/Advanced results C Risk level E Nature of action code
F Date of action (Month/Day/Year) G Geographic location H Position code I Position title J SON (Submitting Office Number)
K Location of Official Personnel Folder None At SON Other Other address/Web address of e-OPF Zip Code
NPRC e-OPF
L SOI (Security Office Identifier) M Location of Security Folder None At SOI e-OPF Other address/Web address of e-OPF Zip Code
NPI Other
N IPAC O TAS P Obligating document number Q BETC
R Accounting data and/or Agency case number S Investigative requirement Initial

Reinvestigation
T Requesting Official - Name Title Signature
Email address Telephone number (Include Ext.) Date (Month/Day/Year)
U Secondary Requesting Official - Name Title
Email address Telephone number (Include Ext.) V Applicant affiliation FED CIV CON
MIL Other
W Deployment/PCS (if imminent)
From (Month/Day/Year) Est. To (Month/Day/Year) Estimated Reason(s) for temporary duty assignment or PCS
Permanent Relocation
Point of contact at location Telephone number (Include Ext.) Address/Unit/Duty location (Include City or Post Name)
Agency Special Instructions for the Investigative Service Provider.
Commercial and Government Entity (CAGE) Code Contract Number
Page 4
PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the
YES NO
penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal
Service.
Section 1 - Full Name

Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle
Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Last Name First Name Middle Name Suffix
Section 2 - Date of Birth Section 3 - Place of Birth

Provide your date of Provide your place of birth.
birth. (Month/Day/Year) City County State Country (Required)
Est.
Section 4 - Social Security Number

Provide your U.S. Social Security Number.
Not applicable
Section 5 - Other Names Used

Have you used any other names? YES NO (If NO, proceed to Section 6)
Complete the following if you have responded 'Yes' to having used other names.
Provide your other name(s) used and the period of time you used it/them [for example: your maiden name, name(s) by a former marriage, former name(s),
alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No
Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Provide other name used
#1 Last name First name Middle name Suffix
From (Month/Year) To (Month/Year) Maiden name? Provide the reason(s) why the name changed
Present
Est. Est. YES NO

Present
Est. Est. YES NO

Present
Est. Est. YES NO

Present
Est. Est. YES NO
Section 6 - Your Identifying Information

Provide your identifying information.
Height Weight (in pounds) Hair color Eye color Sex Female
(feet) (inches) Male
Enter your Social Security Number before going to the next page
Page 5
Section 7 - Your Contact Information
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your
background investigation.
Home e-mail address Work e-mail address
International or DSN phone number Day International or DSN phone number Day International or DSN phone number Day
Home telephone number Extension Night Work telephone number Extension Night Mobile/Cell telephone number Extension Night
Both Both Both
Section 8 - U.S. Passport Information

Do you possess a U.S. passport (current or expired)?
YES NO (If NO, proceed to Section 9)
Provide the following information for the most recent U.S. passport you currently possess.
Passport number Issue date (Month/Day/Year) Expiration date (Month/Day/Year) Click HERE for U.S. State Department passport help
http://travel.state.gov/passport
Est. Est.
Provide the name in which passport was first issued.
Last name First name Middle name Suffix
Section 9 - Citizenship
Select the box that reflects your current citizenship status.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth. I am a derived U.S. citizen. (Complete 9.3)
(Proceed to Section 10)
I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. I am not a U.S. citizen. (Complete 9.4)
(Complete 9.1)
I am a naturalized U.S. citizen. (Complete 9.2)
9.1 Complete the following if you answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide type of documentation of U.S. citizen born abroad.
FS 240 DS 1350 FS 545 Other (Provide explanation)
Provide document number for U.S. citizen born abroad. Provide the date the document was issued. (Month/Day/Year)
Est.
Provide the name in which document was issued.

Provide your citizenship certificate number. Provide the date the certificate was issued. (Month/Day/Year)
Est.
Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)
City State Country
Provide the name in which the certificate was issued.

Were you born on a U.S. military installation? Provide the name of the base.
Page 6
Section 9 - Citizenship - (Continued)
9.2 Complete the following if you answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S. Provide the location of entry into the U.S.
(Month/Day/Year) City State
Est.
Provide country(ies) of prior citizenship.
#1 Country #2 Country
Do/did you have a U.S. alien registration number?

YES Provide your U.S. alien registration number on Certificate of
NO Naturalization - utilize USCIS, CIS, or INS registration, I-551, I-766.
Provide your Certificate of Naturalization number (N550 or N570). Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)
Est.
Provide the name of the court that issued the Provide the address of the court that issued the Certificate of Naturalization.
Certificate of Naturalization. Street City State Zip Code
Provide the name in which the Certificate of Naturalization was issued.

Provide the basis of naturalization.

Based on my own individual naturalization application
Other (Provide explanation)
9.3 Complete the following if you answered that you are a derived U.S. citizen.
Provide your alien registration number (on Certificate of Provide your Permanent Resident Card Provide your Certificate of Citizenship
Citizenship — utilize USCIS, CIS or INS registration number) number (I-551) number (N560 or N561)
Provide the name in which the document was issued.

Provide the date document was issued (Month/Day/Year) Provide the basis of derived citizenship.
Est. By operation of law through my U.S. citizen parent
9.4 Complete the following if you answered that you are not a U.S. citizen.
Provide your residence status. Provide your date of entry in the U.S. (Month/Day/Year)
Est.
Provide your country(ies) of citizenship.

#1 Country #2 Country
Provide your place of entry in the U.S. Provide your alien registration Provide document expiration
City State number (I-551, I-766) date (I-766 ONLY) (Month/Day/Year)
Est.
Provide type of document issued. (I-94, U.S. Visa - red foil number, I-20, DS-2019, etc.)
I-94 U.S. Visa (red foil number) I-20 DS-2019

Provide document number. Provide the date document was issued (Month/Day/Year) Provide document expiration date. (Month/Day/Year)
Est. Est.
Provide the name in which the document was issued.
Page 7
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information
10.1 Do you now or have you EVER held dual/multiple citizenships? YES NO (If NO, proceed to 10.2)
Complete the following if you answered 'Yes' to having EVER held dual/multiple citizenships.
Entry #1
Provide country of citizenship. During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
How did you acquire this non-U.S. citizenship you now have or previously had? From Date (Month/Year) To Date (Month/Year) Present
Est. Est.
Do you currently hold citizenship with this country?
YES NO Provide explanation:
Entry #2
Provide country of citizenship. During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
How did you acquire this non-U.S. citizenship you now have or previously had? From Date (Month/Year) To Date (Month/Year) Present
Est. Est.
Do you currently hold citizenship with this country?
YES NO Provide explanation:
10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.? YES NO (If NO, proceed to Section 11)
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #1
Provide the country in which the passport (or identity card) was issued. Provide the date the passport (or identity card) was issued. (Month/Day/Year)
Est.
Provide the place the passport (or identity card) was issued.
City Country
Provide the name in which passport (or identity card) was issued.
Provide the passport (or identity card) number. Provide the passport (or identity card) expiration date. (Month/Day/Year)
Est.
Have you EVER used this passport (or identity card) for foreign travel?
YES NO
Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country From date (Month/Year) To date (Month/Year)
#1 Est. Est. Present
Page 8
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued)
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #2
Provide the country in which the passport (or identity card) was issued. Provide the date the passport (or identity card) was issued. (Month/Day/Year)
Est.
Provide the place the passport (or identity card) was issued.
City Country
Provide the name in which passport (or identity card) was issued.
Provide the passport (or identity card) number. Provide the passport (or identity card) expiration date. (Month/Day/Year)
Est.
Have you EVER used this passport (or identity card) for foreign travel?
YES NO
Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country From date (Month/Year) To date (Month/Year)
Page 9
Section 11 - Where You Have Lived

List the places where you have lived beginning with your present residence and working back 7 years. Residences for the entire period must be accounted
for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you
were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list
residence before your 18th birthday unless to provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew
you for periods of residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for residence.
Enter residence information.

Entry #1
Provide dates of residence. Is/was this residence:
From (Month/Year) To (Month/Year) Present Owned by you Rented or leased by you
Est. Est. Military housing Other (Provide explanation)
Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City State Zip Code Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
(a) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Street Address/Unit/Duty Location City or Post Name State Zip Code Country
(b) Did you have an APO/FPO address while at this location?

YES Address APO or FPO APO/FPO State Code Zip Code
NO
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address. Provide date of last contact.
Last name First name Middle name Suffix (Month/Year)
Est.
Provide your relationship to this person (Select all that apply).
Neighbor Friend Landlord Business associate Other (Provide explanation)
Provide the following contact information for this person.
I don't know I don't know I don't know
International or DSN phone number International or DSN phone number International or DSN phone number
Evening telephone number Extension Daytime telephone number Extension Cell/mobile telephone number Extension
Provide e-mail address for this person.

I don't know
Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
(b) Does the person who knew you have an APO/FPO address?
NO
Page 10
Section 11 - Where You Have Lived - (Continued)

Entry #2

NO
Est.

I don't know
NO
Page 11

Entry #3

NO
Est.

I don't know
NO
Page 12

Entry #4

NO
Est.

I don't know
NO
Page 13
Section 12 - Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.
(a) Have you attended any schools in the last 7 years? (b) Have you received a degree or diploma more than 7 years ago?
YES NO YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)
Entry #1
Provide the dates of attendance. Select the most appropriate below to describe your school.
From Date (Month/Year) To Date (Month/Year) Present High School Vocational/Technical/Trade School
Est. Est. College/University/Military College Correspondence/Distance/Extension/Online School
Provide the name of the school.
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For
assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Provide the name of the person who knows/knew you at school:
Last name First name
I don't know
Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide telephone number for this person. I don't know Provide email address for this person. I don't know
Telephone number Extension International or DSN phone number
Day Night
Did you receive a degree/diploma?
YES NO
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's, Date awarded
Other degree/diploma Est.
• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other) (Month/Year)
Entry #2
I don't know
Page 14
Section 12 - Where You Went to School - (Continued)
Entry #2 (Continued)
Day Night
YES NO
Entry #3
I don't know
Day Night
YES NO
Page 15
Section 12 - Where You Went to School - (Continued)
Entry #4
I don't know
Day Night
YES NO
Page 16
Section 13A - Employment Activities

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period
must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military
duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment
before your 18th birthday unless to provide a minimum of 2 years employment history.
Entry #1
Select your employment activity:

Active military duty station (Complete 13A.1, 13A.5 State Government (Non-Federal employment) Non-government employment (excluding self-
and 13A.6) (Complete 13A.2, 13A.5 and 13A.6) employment) (Complete 13A.2, 13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5 Self-employment (Complete 13A.3, 13A.5 and
and 13A.6) 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
Unemployment (Complete 13A.4)
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2, Federal Contractor (Complete 13A.2, 13A.5 and Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6) 13A.6) 13A.5 and 13A.6)
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
Provide dates of employment. Select the employment status for Provide your assigned duty station during this period.
this position:
Entry #1
From Date To Date

(Month/Year) (Month/Year)
Present Full-time Provide your most recent rank/position title.
Est. Est. Part-time
Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Day Night Both
(b) Do you or did you have an APO/FPO address while at this location?
NO
Provide the name of your supervisor. Provide the rank/position title of your supervisor.
Provide the email address of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number
Day Night Both
Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).
(b) Do/did your supervisor have an APO/FPO address while at this location?
NO
Page 17
Section 13A - Employment Activities - (Continued)
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
Provide dates of employment. Select the employment status for Provide most recent position title.
Entry #1
this position:
From Date To Date
(Month/Year) (Month/Year) Full-time
Present Provide the name of your employer.
Est. Est. Part-time
Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide telephone number Extension International or DSN phone number

Day Night
Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Not From date (Month/Year) To date (Month/Year) Position Title Supervisor

Applicable Est. Est.
Est. Est.
Est. Est.
Est. Est.
(a) Is/was your physical work address different than your employer's address?
YES NO (If NO, proceed to (b))
Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Day Night
(b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(b.2) Do you or did you have an APO/FPO address while at this location?
NO
Provide the name of your supervisor. Provide the position title of your supervisor.
Day Night
(b) Did/does your supervisor have an APO/FPO address while at this location?
NO
Page 18
13A.3 Complete the following if employment type is self-employment

Entry #1
this position:
From Date To Date
(Month/Year) (Month/Year) Present Full-time Provide the name of your employment.
Est. Est. Part-time
Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide telephone number. Extension International or DSN phone number

Day Night
(a) Is your physical work address different than your employment address?
Provide the telephone number for this address.

Day Night
NO
Provide the name of someone that can verify your self-employment.
Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the telephone number for this person.

Day Night
If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(b) Does your self-employment verifier have an APO/FPO address?

NO
Page 19
13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment. Provide the name of someone that can verify your unemployment activities
and means of support.
Entry #1
From Date (Month/Year) To Date(Month/Year) Last name First name

Present
Est. Est.
Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Verifier telephone number Extension International or DSN phone number
Day Night
If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States,
complete (b).
(b) Does your unemployment verifier have an APO/FPO address?

NO
13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Provide the reason for leaving the employment activity.
Entry #1
For this employment have any of the following happened to you in the last seven (7) years?
● Fired ● Quit after being told you would be fired ● Left by mutual agreement following charges or allegations of misconduct ● Left by mutual agreement
following notice of unsatisfactory performance. YES NO (If NO, proceed to 13A.6)
Select your type of incident: Reason: Employment departure date

Provide the reason for being fired. Provide the date you were fired. (Month/Year)
Fired Est.
Provide the reason for quitting. Provide the date you quit after being told you would be
Quit after being told you would be fired. (Month/Year)
fired Est.
Provide the charges or allegations of misconduct. Provide the date you left following charges or allegations
Left by mutual agreement following of misconduct. (Month/Year)
charges or allegations of misconduct Est.
Provide the reason(s) for unsatisfactory performance. Provide the date you left by mutual agreement following
Left by mutual agreement following a notice of unsatisfactory performance. (Month/Year)
notice of unsatisfactory performance Est.
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
Entry #1
YES NO
#1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year)
Est.
Est.
Est.
Est.
Page 20

Entry #2

and 13A.6) 13A.6)
13A.5 and 13A.6)
13A.5 and 13A.6) 13A.6) 13A.5 and 13A.6)
Entry #2
From Date To Date this position:

Est. Est. Part-time

Day Night Both
NO
Day Night Both
NO
Page 21
Entry #2
this position:
From Date To Date
Est. Est. Part-time

Day Night
as entries below).

Est. Est.
Est. Est.
Est. Est.

Day Night
NO
Day Night
NO
Page 22

Entry #2
this position:
From Date To Date
Est. Est. Part-time

Day Night

Day Night
NO

Day Night
complete (b).

NO
Page 23

Entry #2

Present
Est. Est.

Day Night
complete (b).

NO
Entry #2
Fired Est.
fired Est.
Entry #2
YES NO
Est.
Est.
Est.
Est.
Page 24

Entry #3

and 13A.6) 13A.6)
13A.5 and 13A.6)
13A.5 and 13A.6) 13A.6) 13A.5 and 13A.6)
Entry #3

Est. Est. Part-time

Day Night Both
NO
Day Night Both
NO
Page 25
Entry #3
this position:
From Date To Date
Est. Est. Part-time

Day Night
as entries below).

Est. Est.
Est. Est.
Est. Est.

Day Night
NO
Day Night
NO
Page 26

Entry #3
this position:
From Date To Date
Est. Est. Part-time

Day Night

Day Night
NO

Day Night
complete (b).

NO
Page 27

Entry #3

Present
Est. Est.

Day Night
complete (b).

NO
Entry #3

Fired Est.
fired Est.
Entry #3
YES NO
Est.
Est.
Est.
Est.
Page 28

Entry #4

and 13A.6) 13A.6)
13A.5 and 13A.6)
13A.5 and 13A.6) 13A.6) 13A.5 and 13A.6)
Entry #4

Est. Est. Part-time

Day Night Both
NO
Day Night Both
NO
Page 29
Entry #4
this position:
From Date To Date
Est. Est. Part-time

Day Night
as entries below).

Est. Est.
Est. Est.
Est. Est.

Day Night
NO
Day Night
NO
Page 30

Entry #4
this position:
From Date To Date
Est. Est. Part-time

Day Night

Day Night
NO

Day Night
complete (b).

NO
Page 31

Entry #4

Present
Est. Est.

Day Night
complete (b).

NO
Entry #4

Fired
Est.
fired Est.
Entry #4
YES NO
Est.
Est.
Est.
Est.
Page 32
Section 13B - Employment Activities - Former Federal Service
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
YES NO (If NO, proceed to Section 13C)
Complete the following if you selected "Yes" to having former federal civilian employment, excluding military service, NOT indicated previously.
Entry #1
Provide dates of federal civilian employment. Provide the name of the federal agency for
From Date (Month/Year) To Date (Month/Year) Present which you are/were employed. Provide your position title.
Est. Est.
Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Entry #2
Est. Est.
Entry #3
Est. Est.
Entry #4
Est. Est.
Section 13C - Employment Record

Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed?
- Fired from a job?
- Quit a job after being told you would be fired?
- Have you left a job by mutual agreement following charges or allegations of misconduct?
- Left a job by mutual agreement following notice of unsatisfactory performance?
- Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in
the workplace, such as violation of a security policy?
YES (If YES, you will be required to add an additional employment in Section 13A)
NO (If NO, proceed to Section 14)
Section 14 - Selective Service Record

Were you born a male after December 31, 1959?
Have you registered with the Selective Service System (SSS)? The Selective Service website, www.sss.gov, can help provide the
registration number for persons who have registered. Note: Selective
Yes Provide registration number: Service Number is not your Social Security Number.
No Provide explanation:
I don't know Provide explanation:
Page 33
Section 15 - Military History
Have you EVER served in the U.S. Military?
YES NO (If NO, proceed to 15.2)
15.1(a) Complete the following if you responded 'Yes' to having served in the U.S. Military.
Entry #1
Provide the branch of service you served in. State of service, if Officer or enlisted Provide your service number.
National Guard
Army Air National Not Applicable
Guard
Army National Officer
Marine Corps Provide your status
Guard Provide your dates of service.
Active Duty Enlisted
Navy Coast Guard From Date To Date
Active Reserve (Month/Year) (Month/Year) Present
Air Force Inactive Reserve Est. Est.
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES NO
Provide the type of discharge you received: Provide the date of

Under Other than discharge listed
Honorable Bad Conduct
(Month/Year)
Honorable Conditions
Dishonorable General Other (provide type) Est.
Provide the reason(s) for the discharge, if discharge is other than Honorable
Entry #2
Provide the branch of service you served in. State of service, if Officer or enlisted Provide your service number.
National Guard
Army Air National Not Applicable
Guard
Army National Officer
Marine Corps Provide your status
Guard Provide your dates of service.
Active Duty Enlisted
Navy Coast Guard From Date To Date
Active Reserve (Month/Year) (Month/Year) Present
Air Force Inactive Reserve Est. Est.
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES NO
Provide the type of discharge you received: Provide the date of

Under Other than discharge listed
Honorable Bad Conduct
(Month/Year)
Honorable Conditions
Dishonorable General Other (provide type) Est.
Provide the reason(s) for the discharge, if discharge is other than Honorable
Page 34
Section 15 - Military History - (Continued)

15.1(b) In the last seven (7) years, have you been subject to court martial or other disciplinary procedure YES NO (If NO proceed to 15.2)
under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135
Court of Inquiry, etc?
Complete the following if you responded 'Yes' to In the last seven (7) years, have you been subject to court martial or other disciplinary procedure under the
Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.
Entry #1
Provide the date of the court martial or other disciplinary procedure. (Month/Year)
Est.
Provide a description of the Uniform Code of Military Justice (UCMJ) Provide the name of the disciplinary procedure, such as Court Martial,
offense(s) for which you were charged. Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.
Provide the description of the military court or other authority in which you Provide the description of the final outcome of the disciplinary procedure,
were charged (title of court or convening authority, address, to include city such as found guilty, found not guilty, fine, reduction in rank,
and state or country if overseas). imprisonment, etc.
Entry #2
Provide the date of the court martial or other disciplinary procedure. (Month/Year)
Est.
Provide a description of the Uniform Code of Military Justice (UCMJ) Provide the name of the disciplinary procedure, such as Court Martial,
offense(s) for which you were charged. Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.
Provide the description of the military court or other authority in which you Provide the description of the final outcome of the disciplinary procedure,
were charged (title of court or convening authority, address, to include city such as found guilty, found not guilty, fine, reduction in rank,
and state or country if overseas). imprisonment, etc.
Page 35
Section 15 - Military History - (Continued)

15.2 Have you EVER served, as a civilian or military member in a foreign country's military, intelligence, YES NO (If NO, proceed to Section 16)
diplomatic, security forces, militia, other defense force, or government agency?
Complete the following if you responded 'Yes' to having EVER served as a civilian or military member in a foreign country's military, intelligence, diplomatic,
security forces, militia, other defense force, or government agency.
Entry #1
During your foreign service, which organization were you serving under?
Military (Army, Navy, Air Force, Marines, etc.), Specify
Intelligence Service Security Forces
Diplomatic Service Militia
Other Government Agency, Specify
Other Defense Forces, Specify

Provide the name of the foreign organization. Provide your period of service.
From Date (Month/Year) To Date (Month/Year) Present
Est. Est.
Provide the name of the country. Provide your highest position/rank held. Provide division/department/office in which you served.
Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.
Entry #2
During your foreign service, which organization were you serving under?
Military (Army, Navy, Air Force, Marines, etc.), Specify
Intelligence Service Security Forces
Diplomatic Service Militia
Other Government Agency, Specify
Other Defense Forces, Specify
Provide the name of the foreign organization. Provide your period of service.
Est. Est.
Provide the name of the country. Provide your highest position/rank held. Provide division/department/office in which you served.
Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.
Page 36
Section 16 - People Who Know You Well

Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc.,
who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association with you covers at least
the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.
Entry #1
Provide dates known. Provide relationship to you. (Select all that apply)
From Date (Month/Year) To Date (Month/Year) Present Neighbor Work associate Other (Provide explanation)
Est. Est. Friend Schoolmate
Provide full name.
Provide e-mail address for this person. I don't know Provide rank/title Not applicable
Provide telephone number for I don't know International or DSN Provide mobile/cell telephone I don't know International or DSN
this person. phone number number for this person. phone number
Extension Extension
Day Night Day Night
Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Entry #2
Provide full name.
Extension Extension
Day Night Day Night
Entry #3
Provide full name.
Extension Extension
Day Night Day Night
Page 37
Section 17 - Marital/Relationship Status

Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic partnership:
Never entered in a civil marriage, legally recognized civil union, or legally Separated (Complete 17.1 and 17.3)
recognized domestic partnership (Complete 17.3)
Annulled (Complete 17.2 and 17.3)
Currently in a civil marriage, legally recognized civil union, or legally Divorced/Dissolved (Complete 17.2 and 17.3)
recognized domestic partnership (Complete 17.1 and 17.3)
Widowed (Complete 17.2 and 17.3)
17.1 Complete the following if you selected currently in a civil marriage, legally recognized civil union, or legally recognized domestic partnership or
Separated. Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally recognized
domestic partnership, or the person from whom you are currently separated.
Provide full name. Provide the date of birth.
Last name First name Middle name Suffix (Month/Day/Year)
Est.
Provide place of birth.
City County State Country (required)
If the person is foreign born, provide one type of documentation that he or she possesses and the document number.
U.S. Passport (current or most recent) None (Provide explanation)

FS 240 or 545
DS 1350 Alien Registration
U.S. Certificate of U.S. Certificate of Naturalization

Citizenship
Provide document number. Provide U.S. Social Security Number.

Not applicable
Provide other names used (such as maiden name, names by other marriages, civil marriages, legally recognized
civil unions, or legally recognized domestic partnerships, nicknames, etc., and provide dates used for each name). Not applicable
Maiden name? From (Month/Year) To (Month/Year) Present

Est. Est.

Est. Est.

Est. Est.

Est. Est.
Provide country(ies) of citizenship. Provide date when you entered into your civil
Country #1 Country #2 marriage, civil union, or domestic partnership. (Month/Day/Year)
Est.
Page 38
Section 17 - Marital/Relationship Status - (Continued)
17.1 Complete the following if you selected currently in a civil marriage, legally recognized civil union, or legally recognized domestic partnership or
Separated. Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally recognized
domestic partnership, or the person from whom you are currently separated. (Continued)
Provide location. (Provide City and Country if outside the United States; otherwise, provide City or County and State.)
City County State Country
Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Use my current address
Provide telephone number. Extension Day Use my current telephone number Provide email address.
Night International or DSN phone number
Does the person have an APO/FPO address within the United States?
NO
If you have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/
fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Are you separated? If legally separated, provide the location of the record.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Not Applicable
Provide date of separation.
YES (Month/Day/Year) City State Zip Code Country
NO Est.
Page 39
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report? YES NO
17.2 Complete the following if you selected divorced/dissolved, annulled, or widowed. Provide information about any person from whom you are divorced/
dissolved, annulled, or widowed.
Entry #1
Provide the full name. Provide the date of birth.
Est.
Provide the place of birth.
City State Zip Code Country (Required)
Provide the country(ies) of citizenship.

Country #1 Country #2
Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)
Est.
Provide the location. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
City State Country
Provide the status. Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)
Divorced/Dissolved Widowed Annulled Est.
Provide where the record of divorce/dissolution or annulment is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City State Zip Code Country
Is this person deceased?

YES NO (If NO, complete (a)) I don't know
(a) Provide last known address of the person from whom you are divorced/dissolved or annulled. (Provide City and Country if outside the I don't know
United States; otherwise, provide City, State and Zip Code)
Page 40
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report? YES NO
17.2 Complete the following if you selected "divorced/dissolved", "annulled", or "widowed". Provide information about any person from whom you are
divorced/dissolved, annulled, or widowed.
Entry #2
Provide the full name. Provide the date of birth.
Est.
Provide the place of birth.
City State Zip Code Country (Required)
Provide the country(ies) of citizenship.

Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)
Est.
Provide the location. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
City State Country
Provide the status. Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)
Divorced/Dissolved Widowed Annulled Est.
Provide where the record of divorce/dissolution or annulment is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Is this person deceased?

YES NO (If NO, complete (a)) I don't know
(a) Provide last known address of the person from whom you are divorced/dissolved or annulled. (Provide City and Country if outside the I don't know
United States; otherwise, provide City, State and Zip Code)
Page 41
17.3 Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic YES NO (If NO, proceed to Section 18)
partner, with whom you share bonds of affection, obligation, or other commitment, as opposed to a
person with whom you live for reasons of convenience (e.g. a roommate)? If so, complete the following.
If the person was born outside the U.S., provide citizenship information.
Complete the following if you presently reside with a cohabitant.
Entry #1
Provide the cohabitant full name. Provide the cohabitant date of birth.
Last name First name Middle name Suffix Date (Month/Day/Year)
Est.
Provide the cohabitant place of birth.

City State Country (Required)
For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.

FS 240 or 545

Citizenship
Provide document number. Provide your cohabitant's U.S. Social Security Number.
Not applicable
Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each Not applicable
name was used).

Est. Est.

Est. Est.

Est. Est.

Est. Est.
Provide your cohabitant's country(ies) of citizenship. Provide date cohabitation began.
Country #1 Country #2 (Month/Day/Year)
Est.
Page 42
17.3 Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic YES NO (If NO, proceed to Section 18)
partner, with whom you share bonds of affection, obligation, or other commitment, as opposed to a
person with whom you live for reasons of convenience (e.g. a roommate)? If so, complete the following.
If the person was born outside the U.S., provide citizenship information.
Complete the following if you presently reside with a cohabitant.
Entry #2
Provide the cohabitant full name. Provide the cohabitant date of birth.
Last name First name Middle name Suffix Date (Month/Day/Year)
Est.
Provide the cohabitant place of birth.

City State Country (Required)
For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.

FS 240 or 545

Citizenship
Provide document number. Provide your cohabitant's U.S. Social Security Number.
Not applicable
Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each Not applicable
name was used).

Est. Est.

Est. Est.

Est. Est.

Est. Est.
Provide your cohabitant's country(ies) of citizenship. Provide date cohabitation began.
Country #1 Country #2 (Month/Day/Year)
Est.
Page 43
Section 18 - Relatives
Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.)
Select all that apply.
Mother Foster parent Sister Half-sister
Father Child (including adopted/foster) Stepbrother Father-in-law
Stepmother Stepchild Stepsister Mother-in-law
Stepfather Brother Half-brother Guardian
Entry #1
Provide relative type.
Provide your relative's full name.

Provide your relative's date of birth. Provide your relative's place of birth.
Date (Month/Year) City State Country (Required)
Est.
Provide your relative's country(ies) of citizenship.
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
If mother, provide your mother's maiden name. Same as listed I don't know
Entry #1
Has this relative used any other names?

YES NO
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former Not applicable
name, alias, or nickname).
Maiden name? From (Month/Year) To (Month/Year) Present Provide the reason(s) why the name changed.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
Page 44
Section 18 - Relatives - (Continued)
Is your relative deceased? YES NO (If NO, proceed to 18.2)
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Entry #1
Does this relative have an APO/FPO address?

YES Provide your relative's APO/FPO address.
NO Address APO or FPO APO/FPO State Code Zip Code
I don't know
Page 45

Entry #2

Est.
Entry #2

YES NO
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
Page 46
Entry #2

I don't know
Page 47

Entry #3

Est.
Entry #3

YES NO
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
Page 48
Entry #3

I don't know
Page 49

Entry #4

Est.
Entry #4

YES NO
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
Page 50
Street City State Country
Entry #4
Zip Code

I don't know
Page 51
Entry #5

Est.
Entry #5

YES NO
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
Page 52
Is your relative deceased?

Entry #5

I don't know
Page 53

Entry #6

Est.
Entry #6

YES NO
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
YES NO Est. Est.
Page 54
Entry #6

I don't know
Page 55
Section 19 - Foreign Countries You have Visited

Have you traveled outside the U.S. in the last seven (7) years? YES NO (If NO, proceed to Section 20)
Has your travel in the last seven (7) years been solely for U.S. Government business/military overseas
YES (If YES, proceed to Section 20) NO
assignment on official government orders (i.e., no personal trips in conjunction with the official U.S.
Government business)?
Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business.
Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business
on official government orders.
Entry #1
Provide the country visited. Provide the dates of your travel to this country. Provide the total number of days involved in the visit.
From (Month/Year) To (Month/Year) Present 1-5 11-20 More than 30
Est. Est. 6-10 21-30 Many short trips
Provide the purpose of the travel to this country (Select all that apply).
Business/Professional Education Trade shows, conferences, and seminars Other
Volunteer activities Tourism Visit family or friends
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
YES If yes, provide explanation.
NO
While traveling to or in this country, were you involved in any encounter with the police?
NO
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
NO
Entry #2
NO
NO
NO
Page 56
Section 19 - Foreign Countries You have Visited - Continued
Entry #3
NO
NO

NO
Entry #4
NO
NO
NO
Page 57
Section 20 - Police Record

For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or
the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order
under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.
20.1 Have any of the following happened? (If 'Yes' you will be asked to provide details for each offense that
pertains to the actions that are identified below.) YES NO (If NO, proceed to 20.2)
- In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?
(Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)
- In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
- In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
- In the last seven (7) years have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?
Entry #1
Entry #1
Provide the date of offense. (Month/Year) Provide a description of the specific nature of the offense.
Est.
(a) Did this offense involve any of the following?
YES NO
(Select all that apply.)

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally
recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom you share
a child in common?
Involve firearms or explosives?
Involve alcohol or drugs?
Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City County State Zip Code Country
(b) Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other
type of law enforcement official?
YES NO (If NO, proceed to (c))
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
(c) As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?
YES Provide the name of the court.

(If YES, complete (c.1))
NO Provide explanation
(c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge
dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser
offense.
Felony/misdemeanor Charge Outcome Date (Month/Year)

Est.
Est.
Est.
Est.
Page 58
Section 20 - Police Record - (Continued)
Entry #1
(d) Were you sentenced as a result of this offense?
YES (If YES, complete (d.1)) NO (If NO, complete (d.2))
(d.1)
Provide a description of the sentence.
Entry #1
Were you sentenced to imprisonment for a term exceeding 1 year? YES NO
Were you incarcerated as a result of that sentence for not less than 1 year? YES NO
If the conviction resulted in imprisonment, provide the dates that you Not Applicable From Date (Month/Year) To Date (Month/Year) Present
actually were incarcerated.
Est. Est.
If conviction resulted in probation or parole, provide the dates of Not Applicable From Date (Month/Year) To Date (Month/Year) Present
probation or parole.
Est. Est.
(d.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? YES NO
Provide explanation.
Page 59

Complete the following if you have responded 'Yes' to one of the following;
- In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?
(Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)
- In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
- In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
- In the last seven (7) years have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?
Entry #2
Entry #2
Est.
YES NO
(Select all that apply.)

a child in common?
Involve firearms or explosives?
Involve alcohol or drugs?
Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
(b) Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other
type of law enforcement official?
YES NO (If NO, proceed to (c))
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
(c) As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?
YES Provide the name of the court.

(If YES, complete (c.1))
NO Provide explanation
(c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge
dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser
offense.

Est.
Est.
Est.
Est.
Page 60
Entry #2
(d) Were you sentenced as a result of this offense?
YES (If YES, complete (d.1)) NO (If NO, complete (d.2))
(d.1)
Entry #2
Est. Est.
Est. Est.
(d.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? YES NO
Page 61

20.2 Other than those offenses already listed, have you EVER had the following happen to you? YES NO (If NO, proceed to 20.3)
- Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such as battery or assault) against your
child, dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/
domestic partner, or someone with whom you share a child in common?
Entry #1
Est.
YES NO
a child in common?
Provide the name of the court.
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or
charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser
offense separately.
Est.
Est.
Est.
Est.
(b) Were you sentenced as a result of these charges?
YES (If YES, complete (b.1)) NO (If NO, complete (b.2))

(b.1)
Est. Est.
Est. Est.
(b.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES NO
Page 62
Entry #2
Est.
YES NO
a child in common?
Provide the name of the court.
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or
charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser
offense separately.
Est.
Est.
Est.
Est.
(b) Were you sentenced as a result of these charges?
YES (If YES, complete (b.1)) NO (If NO, complete (b.2))

(b.1)
Did this offense involve any of the following? YES NO
Est. Est.
Est. Est.
(b.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES NO
Page 63

20.3 Is there currently a domestic violence protective order or restraining order issued against you? YES NO (If NO, proceed to Section 21)
Complete the following if you responded 'Yes' to currently having a domestic violence protective order or restraining order issued against you?
Entry #1
Provide the date the order was issued. (Month/Year) Provide the name of the court or agency that issued the order.
Est.
Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Entry #2
Est.
Entry #3
Est.
Entry #4
Est.
Page 64
Section 21 - Illegal Use of Drugs and Drug Activity

You are required to answer the questions. We note, with reference to this section, that neither your truthful responses nor information derived from your
responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not
you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled substances or drug or
controlled substance activity not in accordance with Federal laws, even though permissible under state laws.
21.1 In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or YES NO (If NO, proceed to 21.2)
controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise
consuming any drug or controlled substance.
Complete the following if you answered 'Yes' to in the last seven (7) years having illegally used a drug or controlled substance.
Entry #1
Provide the type of drug or controlled substance.
Cocaine or crack cocaine (Such as rock, freebase, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.) Other (Provide explanation)

Provide an estimate of the month Provide an estimate of the month and Provide nature of use, frequency, and number of times used.
and year of first use. (Month/Year) year of most recent use. (Month/Year)
Est. Est.
Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in
YES NO
a position directly and immediately affecting the public safety?
Was your use while possessing a security clearance? YES NO
Do you intend to use this drug or controlled substance in the future? YES NO
Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Entry #2

Provide an estimate of the month Provide an estimate of the month and Provide nature of use, frequency, and number of times used.
and year of first use. (Month/Year) year of most recent use. (Month/Year)
Est. Est.
Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in
YES NO
a position directly and immediately affecting the public safety?
Was your use while possessing a security clearance? YES NO
Do you intend to use this drug or controlled substance in the future? YES NO
Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Page 65
Section 21 - Illegal Use of Drugs and Drug Activity - (Continued)
21.2 In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation, YES NO (If NO, proceed to 21.3)
trafficking, production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?
Complete the following if you answered 'Yes' to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation,
trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance.
Entry #1

Provide an estimate of the month and Provide an estimate of the month and year Provide the nature and frequency of activity.
year of first involvement. (Month/Year) of most recent involvement. (Month/Year)
Est. Est.
Provide the reason(s) why you engaged in the activity.
Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a YES NO
position directly and immediately affecting the public safety?
Was your involvement while possessing a security clearance? YES NO
Do you intend to engage in this activity in the future?

YES Provide explanation.
NO
Entry #2

Provide an estimate of the month and Provide an estimate of the month and year Provide the nature and frequency of activity.
year of first involvement. (Month/Year) of most recent involvement. (Month/Year)
Est. Est.
Provide the reason(s) why you engaged in the activity.
Do you intend to engage in this activity in the future?

YES Provide explanation.
NO
Page 66
21.3 In the last seven (7) years, have you illegally used or otherwise been involved with a drug or controlled YES NO (If NO, proceed to 21.4)
substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a
position directly and immediately affecting the public safety other than previously listed?
Complete the following if you responded 'Yes' to having in the last seven (7) years, illegally used, or otherwise been involved with a drug or controlled
substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public
safety other than previously listed.
Entry #1
Provide a description of the drugs or controlled substances used and your involvement.
Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this
From Date (Month/Year) To Date (Month/Year) drug or controlled substance while employed in this capacity.
Present
Est. Est.
Entry #2
Provide a description of the drugs or controlled substances used and your involvement.
Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this
From Date (Month/Year) To Date (Month/Year) drug or controlled substance while employed in this capacity.
Present
Est. Est.
Page 67
21.4 In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of YES NO (If NO, proceed to 21.5)
whether or not the drugs were prescribed for you or someone else?
Complete the following if you responded 'Yes' to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless
of whether the drugs were prescribed for you or someone else.
Entry #1
Provide the name of the prescription drug that you misused.
Provide the dates of involvement in the above. Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Est. Est.

Entry #2
Provide the name of the prescription drug that you misused.
Provide the dates of involvement in the above. Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Est. Est.
Page 68
21.5 In the last seven (7) years have you been ordered, advised, or asked to seek counseling or YES NO (If NO, proceed to 21.6)
treatment as a result of your illegal use of drugs or controlled substances?
Complete the following if you responded 'Yes' to In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a
result of your illegal use of drugs or controlled substances.
Entry #1
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances?
(Select all that apply):
An employer, military commander, or employee assistance program A court official / judge
A medical professional I have not been ordered, advised, or asked to seek

counseling or treatment by any of the above.
A mental health professional
Provide explanation
Did you take action to receive counseling or treatment? YES (If YES, complete (b)) NO (If NO, complete (a))
(a) You have indicated that you did not receive treatment.
(b) You have indicated that you did receive treatment.

Provide the type of drug or controlled substance for which you were treated.

Provide the name of the treatment provider.
Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide a telephone number for the Extension International or DSN Provide the dates of treatment.
treatment provider. phone number From Date (Month/Year) To Date (Month/Year) Present
Day Night Est. Est.
Did you successfully complete the treatment? YES NO (Provide explanation)
Page 69
Complete the following if you responded 'Yes' to In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a
result of your illegal use of drugs or controlled substances.
Entry #2
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances?
(Select all that apply):
An employer, military commander, or employee assistance program A court official / judge
A medical professional I have not been ordered, advised, or asked to seek

counseling or treatment by any of the above.
A mental health professional
Provide explanation
(a) You have indicated that you did not receive treatment.
(b) You have indicated that you did receive treatment.


Provide a telephone number for the Extension International or DSN Provide the dates of treatment.
treatment provider. phone number From Date (Month/Year) To Date (Month/Year) Present
Day Night Est. Est.
Page 70
21.6 In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your YES NO (If NO, proceed to Section 22)
use of a drug or controlled substance?
Complete the following if you responded 'Yes' to In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of a
drug or controlled substance.
Entry #1
Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.)
Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation)
Provide a telephone number for the Extension International or DSN phone Provide the dates of treatment.
treatment provider. number From Date (Month/Year) To Date (Month/Year) Present
Day Night Est. Est.
Entry #2
Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.)
Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation)
Provide a telephone number for the Extension International or DSN phone Provide the dates of treatment.
treatment provider. number From Date (Month/Year) To Date (Month/Year) Present
Day Night Est. Est.
Page 71
Section 22 - Use of Alcohol
22.1 In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your YES NO (If NO, proceed to 22.2)
professional or personal relationships, your finances, or resulted in intervention by law enforcement/public
safety personnel?
Complete the following if you responded 'Yes' to your alcohol use having had a negative impact on your work performance, your professional or personal
relationships, your finances, or resulted in intervention by law enforcement/public safety personnel.
Entry #1
Provide the month/year when this negative impact occurred. Provide dates of involvement or use.
From Date (Month/Year) From Date (Month/Year) To Date (Month/Year) Present
Est. Est. Est.
Provide an explanation of the circumstances and the negative impact.
Provide circumstances. Provide negative impact.
Entry #2
Est. Est. Est.

Entry #3
Est. Est. Est.

Entry #4
Est. Est. Est.
Page 72
Section 22 - Use of Alcohol - (Continued)

22.2 In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a YES NO (If NO, proceed to 22.3)
result of your use of alcohol?
Complete the following if you responded 'Yes' to having been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol.
Entry #1
(a) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.
(b) You responded 'Yes' to having taken action to seek counseling or treatment.
Provide the dates of counseling or treatment. Provide the name of the individual counselor or treatment provider.
Est. Est.
Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Day Night
Did you successfully complete the treatment program? YES NO (Provide explanation)
Entry #2
(a) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.
(b) You responded 'Yes' to having taken action to seek counseling or treatment.
Est. Est.
Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Day Night
Page 73
Section 22 - Use of Alcohol - (Continued)
22.3 In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of alcohol? YES NO (If NO, proceed to 23)
Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment.
Entry #1
Est. Est.
Provide the full address of the counseling or treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Day Night
Entry #2
Est. Est.
Provide the full address of the counseling or treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Day Night
Page 74
Section 23 - Investigations and Clearance Record

23.1 Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you
a security clearance eligibility/access?
Complete the following if you responded 'Yes' to the U.S. Government (or a foreign government) having investigated your background and/or having
granted you a security clearance eligibility/access.
Entry #1
Provide the investigating agency:
U.S. Department of Defense U.S. Department of Homeland Security
U.S. Department of State Foreign government (Provide name of government)
U.S. Office of Personnel Management I don't know
Federal Bureau of Investigation Other (Provide explanation)
U.S. Department of Treasury (Provide name of bureau)
Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.
Date the investigation was completed (Month/Year) I don't know Provide the date clearance eligibility/access was granted. (Month/Year) I don't know
Est. Est.
Provide the level of clearance eligibility/access granted:
None Q
Confidential L
Secret I don't know
Top Secret Issued by foreign country
Sensitive Compartmented Information (SCI) Other (Provide explanation)
Entry #2
Provide the investigating agency:
U.S. Department of Defense U.S. Department of Homeland Security
U.S. Department of State Foreign government (Provide name of government)
U.S. Office of Personnel Management I don't know
Federal Bureau of Investigation Other (Provide explanation)
U.S. Department of Treasury (Provide name of bureau)
Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.
Date the investigation was completed (Month/Year) I don't know Provide the date clearance eligibility/access was granted. (Month/Year) I don't know
Est. Est.
Provide the level of clearance eligibility/access granted:
None Q
Confidential L
Secret I don't know
Top Secret Issued by foreign country
Sensitive Compartmented Information (SCI) Other (Provide explanation)
Page 75
Section 23 - Investigations and Clearance Record - (Continued)

23.2 Have you EVER had a security clearance eligibility/access authorization denied, suspended, or
revoked? (Note: An administrative downgrade or administrative termination of a security clearance is
not a revocation.)
Complete the following if you responded 'Yes' to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.
Entry #1
Provide the date security clearance Provide the name of the agency that took Provide an explanation of the circumstances of the
eligibility/access authorization was denied, the action. denial,suspension or revocation action.
suspended or revoked. (Month/Year)
Est.
Entry #2
Provide the date security clearance Provide the name of the agency that took Provide an explanation of the circumstances of the
eligibility/access authorization was denied, the action. denial,suspension or revocation action.
suspended or revoked. (Month/Year)
Est.
23.3 Have you EVER been debarred from government employment? YES NO (If NO, proceed to Section 24)
Complete the following if you responded 'Yes' to having EVER been debarred from government employment.
Entry #1
Provide the name of the government Provide the date the debarment occurred. Provide an explanation of the circumstances of the
agency taking debarment action. (Month/Year) debarment.
Est.
Entry #2
Provide the name of the government Provide the date the debarment occurred. Provide an explanation of the circumstances of the
agency taking debarment action. (Month/Year) debarment.
Est.
Page 76
Section 24 - Financial Record
24.1 In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code? YES NO (If NO, proceed to 24.2)
Complete the following if you responded 'Yes' to in the last seven (7) years having filed a petition under any chapter of the bankruptcy code.
Entry #1
Select the applicable bankruptcy petition type. Provide the bankruptcy court docket/account number.
Chapter 7 Chapter 11 Chapter 12 Chapter 13
Provide the date bankruptcy was Provide the date of bankruptcy Provide the total amount (in U.S.
filed. (Month/Year) discharge. (Month/Year) Not Applicable dollars) involved in the bankruptcy.
Est. Est. Est.
Provide the name debt is recorded under.

Provide the name of the court involved.
Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
(a) If Chapter 13 or Chapter 12 previously selected:

Provide the name of the trustee for this bankruptcy.
Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Were you discharged of all debts claimed in the bankruptcy? YES (Provide explanation) NO (Provide explanation)
Provide Explanation.
Entry #2
Select the applicable bankruptcy petition type. Provide the bankruptcy court docket/account number.
Chapter 7 Chapter 11 Chapter 12 Chapter 13
Provide the date bankruptcy was Provide the date of bankruptcy Provide the total amount (in U.S.
filed. (Month/Year) discharge. (Month/Year) Not Applicable dollars) involved in the bankruptcy.
Est. Est. Est.
Provide the name debt is recorded under.

Provide the name of the court involved.
(a) If Chapter 13 or Chapter 12 previously selected:

Provide the name of the trustee for this bankruptcy.
Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Were you discharged of all debts claimed in the bankruptcy? YES (Provide explanation) NO (Provide explanation)
Provide Explanation.
Page 77
Section 24 - Financial Record - (Continued)
24.2 In the last seven(7) years have you failed to meet financial obligations due to gambling? YES NO (If NO, proceed to 24.3)
Complete the following if you responded 'Yes' to having failed to meet financial obligations due to gambling.
Entry #1
Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.
Est. Est.
Provide a description of your financial problems due to gambling. If you have taken any action(s) to rectify your financial problems due to gambling, provide
a description of your actions. If you have not taken any action(s), provide explanation.
Entry #2
Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.
Est. Est.
Provide a description of your financial problems due to gambling. If you have taken any action(s) to rectify your financial problems due to gambling, provide
a description of your actions. If you have not taken any action(s), provide explanation.
24.3 In the last seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law YES NO (If NO, proceed to 24.4)
or ordinance?
Complete the following if you responded 'Yes' to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Entry #1
Did you fail to file, pay as required, or both? Provide the year you failed to file or pay your Federal, state, or other taxes.
File Pay Both Est.
Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency Provide the type of taxes you failed to file or
to which you failed to file or pay taxes. pay (such as property, income, sales, etc.).
Provide the amount (in U.S. dollars) of the taxes. Provide date satisfied. (Month/Year) Not Applicable
Est. Est.
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not
taken any action(s) provide explanation.
Entry #2
Did you fail to file, pay as required, or both? Provide the year you failed to file or pay your Federal, state, or other taxes.
File Pay Both Est.
Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency Provide the type of taxes you failed to file or
to which you failed to file or pay taxes. pay (such as property, income, sales, etc.).
Provide the amount (in U.S. dollars) of the taxes. Provide date satisfied. (Month/Year) Not Applicable
Est. Est.
taken any action(s) provide explanation.
Page 78

24.4 In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of YES NO (If NO, proceed to 24.5)
agreement for a travel or credit card provided by your employer?
Complete the following if you responded 'Yes' to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card
provided by your employer.
Entry #1
Provide the name of the agency or company.
Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide the reason(s) for the counseling, warning, or disciplinary action.
Provide the amount (in U.S. dollars) Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any
of violation. action(s) provide explanation.
Est.
Entry #2
Provide the name of the agency or company.
Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide the reason(s) for the counseling, warning, or disciplinary action.
Provide the amount (in U.S. dollars) Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any
of violation. action(s) provide explanation.
Est.
24.5 Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to YES NO (If NO, proceed to 24.6)
resolve an inability to meet financial obligations?
Complete the following if you responded 'Yes' to currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve
an inability to meet financial obligations.
Entry #1
Provide explanation. Provide the name of the credit counseling organization or resource.
Provide the telephone number of the credit counseling organization. Provide the location of the credit counseling organization.
Telephone number Extension International or DSN phone number City State
Day Night
As a result of this counseling, provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken
any action(s), provide explanation.
Entry #2
Provide explanation. Provide the name of the credit counseling organization or resource.
Provide the telephone number of the credit counseling organization. Provide the location of the credit counseling organization.
Telephone number Extension International or DSN phone number City State
Day Night
As a result of this counseling, provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken
any action(s), provide explanation.
Page 79

24.6 Other than previously listed, have any of the following happened to you? (You will be asked to provide
details about each financial obligation that pertains to the items identified below)
- You are currently delinquent on alimony or child support payments.
- In the last seven (7) years, you had a judgment entered against you. (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner
or guarantor).
- In the last seven (7) years, you had a lien placed against your property for failing to pay taxes
or other debts. (Include financial obligations for which you were the sole debtor, as well as
those for which you were a cosigner or guarantor).
- You are currently delinquent on any Federal debt. (Include financial obligations for which you
are the sole debtor, as well as those for which you are a cosigner or guarantor).
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Entry #1
Provide the name of agency/organization/individual to which debt is/was owed.
Did/does this financial issue include any of the following? (Select all that apply) YES NO (If NO, proceed to 24.7)
You are currently delinquent on alimony or child support payments.
In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those
for which you were a cosigner or guarantor).
In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).
Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any).
Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue.
Est.
Provide the date the financial Provide date the financial issue Provide the name of the court involved.
issue began. (Month/Year) was resolved. (Month/Year) Not Resolved
Est. Est.
taken any action(s), provide explanation.
Page 80
Entry #2
Did/does this financial issue include any of the following? (Select all that apply) YES NO (If NO, proceed to 24.7)
You are currently delinquent on alimony or child support payments.
In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those
for which you were a cosigner or guarantor).
In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a
Est.
Provide the date the financial Provide date the financial issue Provide the name of the court involved.
issue began. (Month/Year) was resolved. (Month/Year) Not Resolved
Est. Est.
Page 81

24.7 Other than previously listed, have any of the following happened? YES NO (If NO, proceed to Section 25)
- In the last seven (7) years, you had any possessions or property voluntarily or involuntarily
repossessed or foreclosed? (Include financial obligations for which you were the sole debtor,
as well as those for which you were a cosigner or guarantor).
- In the last seven (7) years, you defaulted on any type of loan? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a
- In the last seven (7) years, you had bills or debts turned over to a collection agency?
(Include financial obligations for which you were the sole debtor, as well as those for which
you were a cosigner or guarantor).
- In the last seven (7) years, you had any account or credit card suspended, charged off, or
cancelled for failing to pay as agreed? (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
- In the last seven (7) years, you were evicted for non-payment?
- In the last seven (7) years, you had wages, benefits, or assets garnished or attached
for any reason?
- In the last seven (7) years, you were over 120 days delinquent on any debt not
previously entered? (Include financial obligations for which you were the sole debtor, as well
as those for which you were a cosigner or guarantor).
- You are currently over 120 days delinquent on any debt? (Include financial obligations for
which you are the sole debtor, as well as those for which you are a cosigner or guarantor).
Entry #1
Did/does this financial issue include any of the following? (Select all that apply) YES NO (If NO, proceed to Section 25)
In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor,
In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you were evicted for non-payment?
In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?
In the last seven (7) years, you were over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were
the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you
are a cosigner or guarantor).
Est.
Provide the date the financial issue began. (Month/Year) Provide date the financial issue was resolved. (Month/Year) Not Resolved
Est. Est.
Page 82
Entry #2
Did/does this financial issue include any of the following? (Select all that apply) YES NO (If NO, proceed to Section 25)
In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor,
In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you were evicted for non-payment?
In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?
In the last seven (7) years, you were over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were
the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you
are a cosigner or guarantor).
Est.
Provide the date the financial issue began. (Month/Year) Provide date the financial issue was resolved. (Month/Year) Not Resolved
Est. Est.
Page 83
Section 25 - Use of Information Technology Systems
We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as
evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal
government. The following questions ask about your use of information technology systems. Information technology systems include all related computer
hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection of information.
25.1 In the last seven (7) years have you illegally or without proper authorization accessed or attempted to
access any information technology system?
Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into
any information technology system.
Entry #1
Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense.
Est.
Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Entry #2
Est.
25.2 In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the
above?
Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the above.
Entry #1
Est.
Entry #2
Est.
Page 84
Section 25 - Use of Information Technology Systems - (Continued)
25.3 In the last seven (7) years have you introduced, removed, or used hardware, software, or media in YES NO (If NO, proceed to Section 26)
connection with any information technology system without authorization, when specifically prohibited
by rules, procedures, guidelines, or regulations or attempted any of the above?
Complete the following if you responded 'Yes' to having in the last seven (7) years introduced, removed, or used hardware, software, or media in
connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or
attempted any of the above.
Entry #1
Est.
Entry #2
Est.
Page 85
Section 26 - Involvement in Non-Criminal Court Actions
In the last seven (7) years, have you been a party to any public record civil court action not listed elsewhere on YES NO (If NO, proceed to Section 27)
this form?
Complete the following if you responded 'Yes' to having been a party to any public record civil court action(s) not listed elsewhere on this form in the last
seven (7) years.
Entry #1
Provide the date of the civil action. (Month/Year) Provide the court name.
Est.
Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide details of the nature of the action. Provide a description of the results of the action. Provide the name(s) of the principal parties
involved in the court action.
Entry #2
Provide the date of the civil action. (Month/Year) Provide the court name.
Est.
Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide details of the nature of the action. Provide a description of the results of the action. Provide the name(s) of the principal parties
involved in the court action.
Page 86
Section 27 - Association Record

The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an
adverse employment, security, or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are
dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.
27.1 Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an YES NO (If NO, proceed to 27.2)
awareness of the organization's dedication to that end, or with the specific intent to further such activities?
Complete the following if you responded 'YES' to being or ever having been a member of an organization dedicated to terrorism, either with an awareness of
the organization's dedication to that end, or with the specific intent to further such activities.
Entry #1
Provide the full name of the organization.
Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide the dates of your involvement with the organization. Provide all positions held in the organization, if any. No positions held
Est. Est.
Provide all contributions made to the No contributions made Provide a description of the nature of and reasons for your involvement with the
organization, if any. organization.
Entry #2
Est. Est.
Page 87
Section 27 - Association Record - (Continued)
27.2 Have you EVER knowingly engaged in any acts of terrorism? YES NO (If NO, proceed to 27.3)
Complete the following if you responded 'Yes' to EVER having knowingly engaged in any acts of terrorism.
Entry #1
Describe the nature and reasons for the activity. Provide the dates for any such activities.
Est. Est.
Entry #2
Describe the nature and reasons for the activity. Provide the dates for any such activities.
Est. Est.
27.3 Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by YES NO (Proceed to 27.4)
force?
Complete the following if you responded 'Yes' to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
force.
Entry #1
Provide the reason(s) for advocating acts of terrorism. Provide the dates of advocating acts of terrorism.
Est. Est.
Entry #2
Provide the reason(s) for advocating acts of terrorism. Provide the dates of advocating acts of terrorism.
Est. Est.
Page 88

27.4 Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow YES NO (If NO, proceed to 27.5)
the United States Government, and which engaged in activities to that end with an awareness of the
organization's dedication to that end or with the specific intent to further such activities?
Complete the following if you responded 'Yes' to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the
United States Government, and which engaged in activities to that end with an awareness of the organization's dedication to that end or with the specific
intent to further such activities.
Entry #1
Est. Est.
Entry #2
Est. Est.
Page 89

27.5 Have you EVER been a member of an organization that advocates or practices commission of acts of force YES NO (If NO, proceed to 27.6)
or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the
United States with the specific intent to further such action?
Complete the following if you responded 'Yes' to being or EVER having been a member of an organization that advocates or practices commission of acts of
force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the specific intent to further
such action.
Entry #1
Est. Est.
Provide all contributions (in U.S. dollars) No contributions made Provide a description of the nature of and reasons for your involvement with the
made to the organization, if any. organization.
Entry #2
Est. Est.
Provide all contributions (in U.S. dollars) No contributions made Provide a description of the nature of and reasons for your involvement with the
made to the organization, if any. organization.
Page 90
27.6 Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force? YES NO (If NO, proceed to 27.7)
Complete the following if you responded 'Yes' to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Entry #1
Describe the nature and reasons for the activity. Provide the dates of such activities.
Est. Est.
Entry #2
Describe the nature and reasons for the activity. Provide the dates of such activities.
Est. Est.
27.7 Have you EVER associated with anyone involved in activities to further terrorism? YES NO
Complete the following if you responded 'Yes' to having EVER associated with anyone involved in activities to further terrorism.
Entry #1
Entry #2
Page 91
Additional Comments
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then
sign and date the following certification and the attached release(s).
Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I
further affirm that, to the best of my knowledge, I have not included any classified information herein. I have carefully read the foregoing instructions to
complete this form. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I
understand that intentionally withholding, misrepresenting, falsifying, or including classified information may have a negative effect on my employment
prospects, or job status, or my removal and debarment from Federal service.
Signature (Sign in ink) Date signed (mm/dd/yyyy)
Page 92
UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my
background investigation or reinvestigation to obtain any information relating to my activities, conduct and character from individuals,
schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection
agencies, retail business establishments, or other sources of information. This information may include, but is not limited to, current and
historic academic, residential, achievement, performance, attendance, disciplinary, employment, criminal, financial and credit information,
and publicly available social media information. I authorize the Federal agency conducting my investigation, or reinvestigation, or performing
continuous vetting, to disclose the record of investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility for a public trust position.
I Understand that, for these purposes, publicly available social media information includes any electronic social media information that has
been published or broadcast for public consumption, is available on request to the public, is accessible on-line to the public, is available to
the public by subscription or purchase, or is otherwise lawfully accessible to the public. I further understand that this authorization does not
require me to provide passwords; log into a private account; or take any action that would disclose non-publicly available social media
information.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and
date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management
(OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide
explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of
information, separate specific releases may be needed, and I may be contacted for such releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of Investigation, the
Department of Defense, the Department of Homeland Security, and the Department of State, and any other authorized Federal agency, to
request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or
retention in, a public trust position, in accordance with 5 U.S.C. 9101. I understand that I may request a copy of such records as may be
available to me under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the
investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous
agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by the Federal Government
only for the purposes provided in this Standard Form 85P, and that it may be disclosed by the Government only as authorized by law.
I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and analyses, which will be
maintained in accordance with the Privacy Act.
Photocopies of this authorization with my signature are valid. This authorization is valid for five(5) years from the date signed or upon
termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used Date of birth Social Security Number
Current street address Apt. # City (Country) State ZIP Code Telephone number
Page 93

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
If you answered “Yes” to Section 5 of the Standard Form 85P with the supplemental SF 85P-S, carefully read this authorization to release
information about you, then sign and date.
This is an authorization for the investigator to ask your health practitioner (s) the questions below concerning your mental health consultations.
The U.S. government recognizes the critical importance of mental health and advocates proactive management of mental health conditions to
support the wellness and recovery of Federal employees and others. The government recognizes that mental health counseling and treatment
may provide important support for those who have experienced traumatic events, as well as for those with other mental health conditions.
While most individuals with mental health conditions do not present risks, there may be times when such a condition can affect a person’s
suitability for positions of public trust with the Federal government. Seeking or receiving mental health care for personal wellness and recovery
may contribute favorably to your suitability determination. Your signature will allow the practitioner (s) to answer only those questions identified
below.
Authorization
I am seeking assignment to or retention in a public trust position. As part of the investigation process, I hereby authorize the investigator,
special agent, or duly accredited representative of the authorized Federal agency conducting my background investigation, reinvestigation,
and my health practitioner (s) to provide the information requested below, relating to my mental health consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to my health care provider/
entity. I understand that I may revoke this authorization, except to the extent that action has already been taken based on this authorization.
Further, I understand that this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be
conditioned upon my authorization of this disclosure.
I understand the information disclosed pursuant to this authorization is for use by the Federal Government only for purposes provided in the
Standard Form 85P and will no longer be subject to the HIPAA Privacy Rule, and that the Federal Government may redisclose the information
as authorized by law, subject to Privacy Act safeguards.
Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed or upon
termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used Social Security Number
Current street address Apt. # City (Country) State ZIP Code Telephone number
For Use By Practitioner(s) Only

Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to perform a
position of public trust?
YES NO
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
Dates of treatment?
Signature (Sign in ink) Practitioner name Date signed (mm/dd/yyyy)
Page 94

FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit
Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
The information obtained may be disclosed to other Federal agencies for the above purposes in fulfillment of official
responsibilities to the extent that such disclosure is permitted by law. Information from the consumer report will not be used in
violation of any applicable Federal or state equal employment opportunity law or regulation.
Authorization
I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my initial background investigation and reinvestigation, or my eligibility for a public trust position, to request, and any
consumer reporting agency to provide, such reports for purposes described above.
Note: If you have a security freeze on your consumer or credit report file, we will not be able to access the information
necessary to complete your investigation, which can adversely affect your eligibility for a public trust position. To avoid such
delays, you should expeditiously respond to any requests made to release the credit freeze for the purposes as described
above.
Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I occupy a
public trust position.
Print Name Social Security Number
Signature (Sign in ink) Date signed (mm/dd/yyyy)
Page 95

Questionnaire For Public Trust Positions: Authority To Request This Information

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Questionnaire For Public Trust Positions: Authority To Request This Information

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Standard Form 85P Form approved:

Revised December 2017 QUESTIONNAIRE FOR OMB No. 3206 0258

e. To an agency, office, or other establishment in the executive, legislative,or

i. To provide criminal history record information to the FBI, to help ensure

r. To another Federal agency’s Office of Inspector General when OPM

s. To another Federal agency’s Office of Inspector General in connection

t. To a Federal agency or state unemployment compensation office upon its

AGENCY USE BLOCK "AUB"

R Accounting data and/or Agency case number S Investigative requirement Initial

Email address Telephone number (Include Ext.) Date (Month/Day/Year)

U Secondary Requesting Official - Name Title

Agency Special Instructions for the Investigative Service Provider.

Commercial and Government Entity (CAGE) Code Contract Number

Section 1 - Full Name

Section 2 - Date of Birth Section 3 - Place of Birth

Section 4 - Social Security Number

Section 5 - Other Names Used

Provide other name used

Provide other name used

Provide other name used

Section 6 - Your Identifying Information

Section 7 - Your Contact Information

Both Both Both

Section 8 - U.S. Passport Information

I am a naturalized U.S. citizen. (Complete 9.2)

Provide the name in which document was issued.

Provide the name in which the certificate was issued.

Section 9 - Citizenship - (Continued)

Do/did you have a U.S. alien registration number?

Provide the name in which the Certificate of Naturalization was issued.

Provide the basis of naturalization.

Provide the name in which the document was issued.

Provide your country(ies) of citizenship.

Other (Provide explanation)

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information

#1 Est. Est. Present

#2 Est. Est. Present

#3 Est. Est. Present

#4 Est. Est. Present

#5 Est. Est. Present

#6 Est. Est. Present

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued)

#1 Est. Est. Present

#2 Est. Est. Present

#3 Est. Est. Present

#4 Est. Est. Present

#5 Est. Est. Present

#6 Est. Est. Present

Section 11 - Where You Have Lived

Enter residence information.

(b) Did you have an APO/FPO address while at this location?

Provide e-mail address for this person.

Section 11 - Where You Have Lived - (Continued)

Enter residence information.

(b) Did you have an APO/FPO address while at this location?

Provide e-mail address for this person.

Section 11 - Where You Have Lived - (Continued)

Enter residence information.