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Investigation Request #24261BARN0808075 for Applicant SSN 232-35-7488 Archival Copy
National Background Investigation Services (NBIS)

Investigation Request #24261BARN0808075
ARCHIVAL COPY - RETAIN FOR YOUR RECORDS
The information contained in this document represents data submitted by Ryan Barnett (Applicant)
for the NBIS Investigation Request #24261BARN0808075. Applicant certified the accuracy of this
information on 2024-09-17.
This Investigation Request contains the following documents:
Page 1: Investigation Request Cover Sheet - SF86 2020-02

Page 2-27: Questionnaire For National Security Positions
Note: To conserve paper only the first entry in multiple-entry lists displays completion instructions. The
completion instructions for the first entry also applies to each additional entry unless otherwise noted.
Certified at 2024-09-17 20:17:57.301 PRIVACY ACT INFORMATION

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b678199f1abe3ae648dff018b2bd23927b92ae249f38ea91276d2d536ebfdc3f
Form Completion Instructions

Instructions Provided By Your Agency
Questionnaire for National Security Positions

Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the
office that provided you the form.
All questions on this form must be answered completely and truthfully in order that the Government may make
the determinations described below on a complete record. Penalties for inaccurate or false statements are discussed
below. If you are a current civilian employee of the federal government: failure to answer any questions completely
and truthfully could result in an adverse personnel action against you, including loss of employment; with respect to
Sections 23, 27, and 29, however, neither your truthful responses nor information derived from those responses will
be used as evidence against you in a subsequent criminal proceeding.
Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting background investigations,
reinvestigations, and continuous evaluations of persons under consideration for, or retention of, national security
positions as defined in 5 CFR 1400, and for individuals requiring eligibility for access to classified information under
Executive Order 12968. This form may also be used by agencies in determining whether a subject performing work
for, or on behalf of, the Government under a contract should be deemed eligible for logical or physical access when
the nature of the work to be performed is sensitive and could bring about an adverse effect on the national security.
Providing this information is voluntary. If you do not provide each item of requested information, however, we will
not be able to complete your investigation, which will adversely affect your eligibility for a national security position,
eligibility for access to classified information, or logical or physical access. It is imperative that the information provided
be 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.
Withholding, misrepresenting, or falsifying information may affect your eligibility for access to classified information,
eligibility for a sensitive position, or your ability to obtain or retain Federal or contract employment. In addition,
withholding, misrepresenting, or falsifying information may affect your eligibility for physical and logical access to
federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also
negatively affect your employment prospects and job status, and the potential consequences include, but are not
limited to, removal, debarment from Federal service, loss of eligibility for access to classified information, or
prosecution.
This form may become a permanent document that may be used as the basis for future investigations, eligibility
determinations for access to classified information, or to hold a sensitive position, suitability or fitness for Federal
employment, fitness for contract employment, or eligibility for physical and logical access to federally controlled
facilities or information systems. Your responses to this form may be compared with your responses to previous
SF-86 questionnaires.
The investigation conducted on the basis of information provided on this form may be selected for studies and
analyses in support of evaluating and improving the effectiveness and efficiency of the investigative and adjudicative
methodologies. All study results released to the general public will delete personal identifiers such as name, Social
Security Number, and date and place of birth.
Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information
under Executive Orders 10577, 10865, 12333, 12968, 13467, and 13488, as amended; sections 3301, 3302, and
9101 and 11001 of title 5, United States Code (U.S.C.); sections 272b, 290a, and 2519 of title 22 , U.S.C.; section
1537 of title 31, U.S.C.; sections 1874, 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50, U.S.C.; section 20132
of title 51, U.S.C; section 925 of Public Law 115-91; parts 2, 5, 6, 731, 732, 736 and 1400 of title 5, Code of Federal
Regulations (CFR); and Homeland Security Presidential Directive (HSPD) 12.

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Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN
is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation.
The authority for soliciting and verifying your SSN is Executive Order 9397, as amended by EO 13478.
The Investigative Process
Background investigations for national security positions are conducted to gather information to determine whether
you are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide
on this form may be confirmed during the investigation. The investigation may extend beyond the time covered by
this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation,
although you may have previously indicated on applications or other forms that you do not want your current employer
to be contacted.
In addition to the questions on this form, inquiry also is made about your adherence to security requirements, your
honesty and integrity, vulnerability to exploitation or coercion, falsification, misrepresentation, and any other behavior,
activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal. Federal agency
records checks may be conducted on your spouse or legally recognized civil union/domestic partner, cohabitant(s),
and immediate family members. After an eligibility determination has been completed, you also may be subject to
continuous evaluation, which may include periodic reinvestigations, to determine whether retention in your position
is clearly consistent with the interests of national security.
The information you provide on this form may be confirmed during the investigation, and
may be used for identification purposes throughout the investigation process.
Your Personal Interview
Some investigations will include an interview with you as a routine part of the investigative process. The investigator
may ask you to explain your answers to any question on this form. This provides you the opportunity to update,
clarify, and explain information on your form more completely, which often assists in completing your investigation.
It is imperative that the interview be conducted as soon as possible after you are contacted. Postponements will
delay the processing of your investigation, and declining to be interviewed may result in your investigation being
delayed or canceled.
For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may
be required to provide other documents to verify your identity, as instructed by your investigator. These documents
may include certification of any legal name change, Social Security card, 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 matters
requiring specific attention. These matters include (a) alien registration or naturalization documentation; (b) delinquent
loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody
or support, alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters
described in court records.
Instructions for Completing this Form
1. Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions,
provided by that office, to assist you with completion of this form. You must sign and date, in ink, the original and
each copy you submit. You should retain a copy of the completed form for your records.
2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form
by checking the associated "Not Applicable" box, unless otherwise noted.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name,
you may select the country name by using the country dropdown feature.
4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be
provided. For locations outside of the U.S. and its territories, select the country in the "Country" dropdown list and
leave the "State" field blank.
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 Service to assist you with Zip Codes.
6. For telephone numbers in the U.S., ensure that the area code is included.
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7. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the dropdown lists to select
the month and day. The year should be entered as a four character number ( i.e., 1978 or 2001.), or selected from
a dropdown list. If you are unable to report an exact date, approximate or estimate the date to the best of your ability,
and indicate this by checking the "Est." box.
Final Determination on Your Eligibility
Final determination on your eligibility for a national security position is the responsibility of the Federal agency that
requested your investigation and the agency that conducted your investigation. You will be provided the opportunity
to explain, refute, or clarify any information before a final decision is made, if an unfavorable decision is considered.
The United States Government does not discriminate on the basis of prohibited categories, including but not limited
to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, or sexual orientation
when granting access to classified information.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly 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 generally
fire, do not grant a security clearance, or disqualify individuals who have materially and deliberately falsified these
forms, and this remains a part of the permanent record for future placements. Your prospects of placement or security
clearance are better if you answer all questions truthfully and completely. You will have adequate opportunity to
explain any information you provide on this form and to make your comments part of the record.
Disclosure Information
The information you provide is for the purpose of investigating you for a national security position, and the information
will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative
information are governed by the Privacy Act. The agency that requested the investigation and the agency that
conducted the investigation have published notices in the Federal Register describing the systems of records in
which your records will be maintained. The information you provide on this form, and information collected during
an investigation, may be disclosed without your consent by an agency maintaining the information in a system of
records as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list of which are published by the
agency in the Federal Register.
You will not receive prior notice of such disclosures under a routine use.
The Defense Counterintelligence and Security Agency, the Government’s primary investigative service provider,
has published its routine uses in the Federal Register at the following address:
https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records. If another
agency is conducting your investigation, it will inform you of its routine uses.
Public Burden Information
Public burden reporting for this collection of information is estimated to average 150 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to U.S. Office of Personnel
Management, Suitability Executive Agent Programs, Attn: OMB Number 3206-0005, 1900 E Street, N.W., Washington,
DC 20415. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.
Statement of Understanding
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 penalties for inaccurate or false statement (per U.S. Criminal Code, Title 18, section 1001), denial or
revocation of a security clearance, and/or removal and debarment from Federal Service.
Yes: { x } No: { }
Box IS Checked! . Box NOT Checked! .

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Sections 1-4 - Identifying Information

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: Barnett First: Ryan Middle: Patrick Suffix: . . . Field is blank!
Provide your date of birth

Month/Day/Year: 08/13/1985 .
Provide your place of birth

City: Morgantown County: Monongalia State: WV Country: United States . . . .
Provide your U.S. Social Security Number ( Not Applicable: { } ) Box NOT Checked! .
232 - 35 - 7488 .
Section 5 - Other Names Used

Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by
a former marriage(s), former name(s), alias(es), or nickname(s)).
Have you used any other names?

Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .
Summary
Section 6 - Your Identifying Information
Provide your identifying information.
Height
(feet): 5 .
(inches): 11 .
Weight: 175 .
Hair color: Brown .
Eye color: Brown .
Sex
Female: { } Box NOT Checked! .
Male: { x } Box IS Checked! .
Section 7 - Your Contact Information

Provide your contact information. Email addresses may be used as a contact method, and identify subject in records.
Home e-mail address: rpb311@gmail.com .
Work e-mail address: rpb311@gmail.com .
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist
in the completion of your background investigation.
Home telephone number
International or DSN: { } Number: Extension: Time: Box NOT Checked! . Field is blank! Field is blank! Field is blank!
Work telephone number

Mobile/Cell telephone number

International or DSN: { } Number: 3048800701 Extension: Time: Both Box NOT Checked! . . Field is blank! .
Section 8 - U.S. Passport Information
Do you possess a U.S. passport (current or expired)?

Yes: { } No: { x }

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Click HERE for U.S. State Department passport help.

Section 9 - Citizenship
Select the box that reflects your current citizenship status and click Save.
Provide your current citizenship status
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.: { x } Box IS Checked! .
I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.: { } Box NOT Checked! .
I am a naturalized U.S. citizen.: { } Box NOT Checked! .
I am a derived U.S. citizen.: { } Box NOT Checked! .
I am not a U.S. citizen.: { } Box NOT Checked! .
Section 10 - Dual/Multiple Citizenship Information
Do you now or have you EVER held dual/multiple citizenships?

Yes: { } No: { x } Box NOT Checked! . Box IS Checked! .
Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?
Section 11 - Where You Have Lived

List the places where you have lived beginning with your present residence and working back 10 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 residences completely outside this 3-year period, and do not list your spouse,
cohabitant or other relatives as the verifier for periods of residence.
1. Enter residence information.

Provide dates of residence
From (Month/Year): 04/2016 (Estimated) To (Month/Year): Present . .
Is/was this residence

Owned by you: { x } Box IS Checked! .
Rented or leased by you: { } Box NOT Checked! .
Military housing: { } Box NOT Checked! .
Other (Provide explanation): { } Box NOT Checked! .
Explanation
Field is blank!
Provide the street address

Street: 1310 CHERRY ST .
City: SUMMERSVILLE State: WV Country: Zip Code: 26651 . . Field is blank! .
Provide the name of a neighbor, landlord (if rental) or other person who knows you at this address.
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Provide the full name

Last: Barnett First: Kristian Middle: Hanson Suffix: . . . Field is blank!
Provide date of last contact

Month/Year: 09/2024 .
Provide your relationship to this person (check all that apply)

Neighbor: { } Box NOT Checked! .
Friend: { } Box NOT Checked! .
Landlord: { } Box NOT Checked! .
Business associate: { } Box NOT Checked! .
Other (Provide explanation): { x } Box IS Checked! .
Explanation
Spouse .
Provide the following contact information for this person

Provide evening telephone number for this person ( I don't know: { } ) Box NOT Checked! .
International or DSN: { } Number: 3046187805 Extension: Box NOT Checked! . . Field is blank!
Provide daytime telephone number for this person ( I don't know: { } ) Box NOT Checked! .
Provide cell/mobile telephone number for this person ( I don't know: { } ) Box NOT Checked! .
Provide e-mail address for this person ( I don't know: { } ) : kwynne220@gmail.com Box NOT Checked! . .
Provide street address for this person (including apartment number)

2. Enter residence information.

Provide dates of residence
From (Month/Year): 01/2011 (Estimated) To (Month/Year): 03/2016 (Estimated) . .
Is/was this residence

Owned by you: { x } Box IS Checked! .
Rented or leased by you: { } Box NOT Checked! .
Military housing: { } Box NOT Checked! .
Explanation
Field is blank!
Provide the street address

Street: 308 TOWNSEND DR .
(End of List)
Do you have an additional residence to report?

Yes: { } No: { x }Box NOT Checked! . Box IS Checked! .
Section 12 - Where You Went To School
Have you attended any schools in the last 10 years?

Yes: { x } No: { } Box IS Checked! . Box NOT Checked! .

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Provide the dates of attendance

1. From (Month/Year): 08/2018 To (Month/Year): 05/2019 . .
Select the most appropriate code to describe your school

High School: { } Box NOT Checked! .
College/University/Military College: { x } Box IS Checked! .
Vocational/Technical/Trade School: { } Box NOT Checked! .
Correspondence/Distance/Extension/Online School: { } Box NOT Checked! .
Provide the name of the school: New River Community and Technical College .
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the
address where the records are maintained.
Street: 6101 WEBSTER RD .
For assistance determining the school address, refer to http://ope.ed.gov/accreditation/Search.aspx
Did you receive a degree/diploma?

(End of List)
Do you have additional education to enter (include education within the last 10 years, as well as degrees or diplomas
more than 10 years ago)?
Yes: { } No: { x }Box NOT Checked! . Box IS Checked! .
Section 13A - Employment Activities

List all of your employment activities, including unemployment and self-employment, beginning with the present and
working back 10 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.
Select your employment activity: State Government (Non-Federal employment) .
1.
Explanation
Field is blank!
Provide dates of employment

From (Month/Year): 03/2019 To (Month/Year): Present . .
Provide most recent position title: Corporal .
Select the employment status for this position

Full-time: { x } Box IS Checked! .
Part-time: { } Box NOT Checked! .
Provide the name of your employer: Summersville Police Department .
Provide the address of employer

Street: 400 BROAD ST .
Provide telephone number

International or DSN: { } Number: 3048721920 Extension: Time: Day Box NOT Checked! . . Field is blank! .
Additional Periods of Activity with this Employer

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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.
Additional Periods of Activity with this Employer ( Not Applicable: { x } ) Box IS Checked! .
Is/was your physical work address different than your employer's address?
Yes: { } No: { x }
Provide the name of your supervisor: Tim Blake .
Provide the position title of your supervisor: Captain .
Provide the email address of your supervisor ( I don't know: { } ) : Tblake@summersvillewv.org Box NOT Checked! . .
Provide the physical work location of your supervisor

Street: 400 BROAD STREET .
Provide the telephone number for this supervisor

International or DSN: { } Number: 3048721920 Extension: Time: Day Box NOT Checked! . . Field is blank! .
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?
Yes: { } No: { x }
Select your employment activity: Non-government employment (excluding self-employment) .
2.
Explanation
Field is blank!
Provide dates of employment

From (Month/Year): 04/2010 To (Month/Year): 03/2019 . .
Provide most recent position title: Aerial Guide/Course Manager .
Select the employment status for this position

Full-time: { x } Box IS Checked! .
Part-time: { } Box NOT Checked! .
Provide the name of your employer: Adventures on the Gorge .
Provide the address of employer

Street: 219 CHESTNUTBURG ROAD .
City: LANSING State: WV Country: Zip Code: 25862 . . Field is blank! .
Provide telephone number

Additional Periods of Activity with this Employer ( Not Applicable: { x } ) Box IS Checked! .
Is/was your physical work address different than your employer's address?
Yes: { } No: { x }
Provide the name of your supervisor: Joe Parrish .
Provide the position title of your supervisor: Department Manager .
Provide the email address of your supervisor ( I don't know: { x } ) : Box IS Checked! . Field is blank!
Provide the physical work location of your supervisor

Street: 219 CHESTNUTBURG ROAD .
City: LANSING State: WV Country: Zip Code: 25862 . . Field is blank! .
Provide the telephone number for this supervisor

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Provide the reason for leaving the employment activity

New Employment .
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: { x }
Summary of Reasons for Leaving
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?
Yes: { } No: { x }
(End of List)
Do you have an additional employment activity to enter?

Yes: { } No: { x }
Section 13B - Former Federal Service
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
Yes: { } No: { x }
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? (If 'Yes', you will be required to add an additional employment in Section 13A.)
• 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: { } No: { x }
Section 14 - Selective Service Record
Were you born a male after December 31, 1959?

Have you registered with the Selective Service System (SSS)?

Yes: { x } No: { } I don't know: { }
Box IS Checked! . Box NOT Checked! . Box NOT Checked! .
The Selective Service website, www.sss.gov , can help provide the registration number for persons who have
registered.
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Note: Selective Service Number is not your Social Security Number

Provide registration number: 8509614288 .
Section 15 - Military History
Have you EVER served in the U.S. Military?

Have you 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?
Yes: { } No: { x }
Section 16 - People Who Know You Well
Provide dates known

1. From (Month/Year): 01/2010 (Estimated) To (Month/Year): Present . .
Provide full name

Last: Shaw First: Leon Middle: (NMN) Suffix: . . . Field is blank!
Provide rank/title ( Not Applicable: { } ) : Federal Agent Box NOT Checked! . .
Provide relationship to you (Check all that apply)

Friend: { x } Box IS Checked! .
Work associate: { } Box NOT Checked! .
Schoolmate: { } Box NOT Checked! .
Explanation
Field is blank!
Provide telephone number for this person ( I don't know: { x } ) Box IS Checked! .
Provide mobile/cell telephone number for this person ( I don't know: { } ) Box NOT Checked! .
Provide e-mail address for this person ( I don't know: { } ) : Lmshaw1977@yahoo.com Box NOT Checked! . .
Provide home or work address for this person

Street: 532 SHEARWATER DRIVE .
City: FORSTON State: GA Country: Zip Code: 31808 . . Field is blank! .
Provide dates known

Provide full name

Last: Cruse First: Jon Middle: Dale Suffix: . . . Field is blank!
Provide rank/title ( Not Applicable: { } ) : Teacher Box NOT Checked! . .

Explanation
Field is blank!

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Provide e-mail address for this person ( I don't know: { x } ) : Box IS Checked! . Field is blank!

Street: 609 HOLLY DR .
Provide dates known

Provide full name

Last: Frame First: Kristina Middle: L (IO) Suffix: . . . Field is blank!
Provide rank/title ( Not Applicable: { } ) : Principal Box NOT Checked! . .

Explanation
Field is blank!
Provide e-mail address for this person ( I don't know: { x } ) : Box IS Checked! . Field is blank!

Street: 175 POWER PLANT RD .
(End of List)
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.
Do you have an additional person who knows you well to list?

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: Currently in a civil marriage, legally recognized civil union, or legally
recognized domestic partnership .
1. You selected "Currently in a civil marriage," "Currently in a 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
Last: Barnett First: Kristian Middle: Hanson Suffix: . . . Field is blank!

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Provide date of birth

Provide place of birth

City: Lewisburg County: Greenbrier State: WV Country: United States . . . .
Provide U.S. Social Security Number ( Not Applicable: { } ) Box NOT Checked! .
233 - 37 - 6294 .
Provide other names used (such as maiden names, 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: { } ) Box NOT Checked! .
Name
1. Last: Wynne First: Kristian Middle: Hanson Suffix: . . . Field is blank!
Maiden name?: { x } Box IS Checked! .
Dates used
From (Month/Year): 02/1988 To (Month/Year): 05/2016 . .
(End of Provide other names used (such as maiden names, names by other marriages, civil marriages, legally recognized civil unions, or
legally recognized domestic partnerships, nicknames, etc. and provide dates used for each name) List)
Provide country(ies) of citizenship
Country: United States .
1.
(End of Provide country(ies) of citizenship List)

Provide the telephone number ( I don't know: { } Use my current telephone number: { } ) Box NOT Checked! . Box NOT Checked! .
Provide date when you entered into your civil marriage, civil union, or domestic partnership
Month/Day/Year: 05/15/2016 (Estimated) .
Provide location
City: Summersville County: Nicholas State: WV Country: . . . Field is blank!
Provide current address if different than your current address ( Use my current address: { x } ) Box IS Checked! .
Street: Field is blank!
City: State: Country: Zip Code:

Field is blank! Field is blank! Field is blank! Field is blank!
Provide email address: kwynne220@gmail.com .
Are you separated?

(End of List)
Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?
Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic 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.
Section 18 - Relatives

Data Hash Code:
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.)
Check all that apply
Mother: { x } Box IS Checked! .
Father: { x } Box IS Checked! .
Stepmother: { } Box NOT Checked! .
Stepfather: { } Box NOT Checked! .
Foster Parent: { } Box NOT Checked! .
Child (including adopted/foster): { x } Box IS Checked! .
Stepchild: { } Box NOT Checked! .
Brother: { x } Box IS Checked! .
Sister: { x } Box IS Checked! .
Stepbrother: { } Box NOT Checked! .
Stepsister: { } Box NOT Checked! .
Half-brother: { } Box NOT Checked! .
Half-sister: { } Box NOT Checked! .
Father-in-law: { x } Box IS Checked! .
Mother-in-law: { x } Box IS Checked! .
Guardian: { } Box NOT Checked! .
Provide relative type: Mother .
1.
Provide your relative's full name
Last: Barnett First: Diane Middle: Kay Suffix: . . . Field is blank!
Provide your relative's date of birth

Provide your relative's place of birth

City: Fairmont State: WV Country: United States . . .
Provide your relative's country(ies) of citizenship
1.
(End of Provide your relative's country(ies) of citizenship List)

Provide your mother's maiden name ( Same as listed: { } ) Box NOT Checked! .
Last: Plymale First: Diane Middle: Kay Suffix: . . . Field is blank!
Has this relative used any other names?

Yes: { } No: { x }
Is your relative deceased?

Yes: { } No: { x }
Provide your relative's current address

Street: 1600 MONTANA AVE .
Provide relative type: Father .
2.
Last: Barnett First: Kenneth Middle: James Suffix: . . . Field is blank!


Data Hash Code:
City: San Antonio State: TX Country: United States . . .
1.

Yes: { } No: { x }

Yes: { } No: { x }

Street: 1600 MONTANA AVE .
Provide relative type: Child (including adopted/foster) .
3.
Last: Barnett First: Auriana Middle: Kayann Suffix:
. . . Field is blank!


City: Beckley State: WV Country: United States
. . .
1.

Yes: { } No: { x }

Yes: { } No: { x }

Provide relative type: Child (including adopted/foster) .
4.
Last: Barnett First: Mia Middle: Jane Suffix:


City: Summersville State: WV Country: United States . . .

Data Hash Code:
1.

Yes: { } No: { x }

Yes: { } No: { x }

Provide relative type: Brother .
5.
Last: Barnett First: Kenneth Middle: Justin Suffix:


City: Fairmont State: WV Country: United States
. . .
1.

Yes: { } No: { x }

Yes: { } No: { x }

Street: 9 WOODCLYFFE RD .
City: HURRICANE State: WV Country: Zip Code: 25526 . . Field is blank! .
Provide relative type: Brother .
6.
Last: Barnett First: Eric Middle: Brandon Suffix:


City: Morgantown State: WV Country: United States . . .

Data Hash Code:
1.

Yes: { } No: { x }

Yes: { } No: { x }

Street: 250 LARK DR .
City: YORK HAVEN State: PA Country: Zip Code: 17370 . . Field is blank! .
Provide relative type: Sister .
7.
Last: Stull First: Julie Middle: Lynn Suffix: . . . Field is blank!


City: Morgantown State: WV Country: United States . . .
1.

Summary of other names used
1. Provide other names used and the period of time that your relative used them (such as maiden name,
by a former marriage, former name, alias, or nickname).
Provide other name used
Last: Barnett First: Julie Middle: Lynn Suffix: . . . Field is blank!
Maiden name?
Yes: { x } Box IS Checked! .
No: { } Box NOT Checked! .
Dates used
From (Month/Year): 06/1983 (Estimated) To (Month/Year): 01/2003 (Estimated) . .
Provide the reason(s) why the name changed

Marriage .
(End of List)
Has this relative used any additional names?

Yes: { } No: { x }

Data Hash Code:

Yes: { } No: { x }

Street: 606 ASHLEY LN .
Provide relative type: Mother-in-law .
8.
Last: Dooley First: Dawn Middle: (NMN) Suffix:


City: Huntington State: WV Country: United States . . .
1.

Yes: { } No: { x }

Street: 374 CLARISSA DR .
Provide relative type: Father-in-law .
9.
Last: Wynne First: Dave Middle: S (IO) Suffix:


City: Princeton State: WV Country: United States
. . .
1.

Yes: { } No: { x }

Street: 117 WC STREET .
City: BECKLEY State: WV Country: Zip Code: 25801

. . Field is blank! .
(End of List)
Do you have an additional relative to enter?

Data Hash Code:
Yes: { } No: { x }
Section 19 - Foreign Contacts

A foreign national is defined as any person who is not a citizen or national of the U.S.
Do you have, or have you had, close and/or continuing contact with a foreign national within the last seven (7)
years with whom you, or your spouse, or legally recognized civil union/domestic partner, or cohabitant are bound
by affection, influence, common interests, and/or obligation? Include associates as well as relatives, not previously
listed in Section 18.
Yes: { } No: { x }
Section 20A - Foreign Activities
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children EVER
had any foreign financial interests (such as stocks, property, investments, bank accounts, ownership of corporate
entities, corporate interests or exchange traded funds (ETFs) held in specific geographical or economic sectors) in
which you or they have direct control or direct ownership? (Exclude financial interests in companies or diversified
mutual funds or diversified ETFs that are publicly traded on a U.S. exchange.)
Yes: { } No: { x }
had any foreign financial interests that someone controlled on your behalf?
Yes: { } No: { x }
owned, or do you anticipate owning, or plan to purchase real estate in a foreign country?
Yes: { } No: { x }
As a U.S. citizen, have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent
children received in the last seven (7) years, or are eligible to receive in the future, any educational, medical,
retirement, social welfare, or other such benefit from a foreign country?
Yes: { } No: { x }
Have you EVER provided financial support for any foreign national?
Yes: { } No: { x }
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts
Have you in the last seven (7) years provided advice or support to any individual associated with a foreign business
or other foreign organization that you have not previously listed as a former employer? (Answer 'No' if all your advice
or support was authorized pursuant to official U.S. Government business.)
Yes: { } No: { x }

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Has any foreign national in the last seven (7) years offered you a job, asked you to work as a consultant, or consider
employment with them?
Yes: { } No: { x }
Have you in the last seven (7) years been involved in any other type of business venture with a foreign national
not described above (own, co-own, serve as business consultant, provide financial support, etc.)?
Yes: { } No: { x }
Have you in the last seven (7) years attended or participated in any conferences, trade shows, seminars, or
meetings outside the U.S.? (Do not include those you attended or participated in on official business for the U.S.
government.)
Yes: { } No: { x }
For Section 20B, 'Immediate Family' means your spouse or legally recognized civil union/domestic partner, parents,
step-parents, siblings, half and step-siblings, children, step-children, and cohabitant.
Have you or any member of your immediate family in the last seven (7) years had any contact with a foreign
government, its establishment (such as embassy, consulate, agency, military service, intelligence or security service,
etc.) or its representatives, whether inside or outside the U.S.? (Answer 'No' if the contact was for routine visa
applications and border crossings related to either official U.S. Government travel, foreign travel on a U.S. passport,
or as a U.S. military service member in conjunction with a U.S. Government military duty.)
Yes: { } No: { x }
Have you in the last seven (7) years sponsored any foreign national to come to the U.S. as a student, for work, or
for permanent residence?
Yes: { } No: { x }
Have you EVER held political office in a foreign country?

Yes: { } No: { x }
Have you EVER voted in the election of a foreign country?

Yes: { } No: { x }
Section 20C - Foreign Travel
Have you traveled outside the U.S. in the last seven (7) years?
Yes: { } No: { x }
Respond for the time frame of the last seven (7) years, beginning with the most recent and working backwards
(Do not list trips that ONLY involved travel on official U.S. Government business on official government orders, but
you must include any personal trips made in conjunction with the official U.S. Government travel).
Section 21 - Psychological and Emotional Health
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. Every day individuals
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with mental health conditions carry out their duties without presenting a security risk. While most individuals with
mental health conditions do not present security risks, there may be times when such a condition can affect a person's
eligibility for a security clearance.
Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce,
major injury, service in a military combat environment, sexual assault, domestic violence, or other difficult work-related,
family, personal, or medical issues may lead to grief, depression, or other responses. The government recognizes
that mental health counseling and treatment may provide important support for those who have experienced such
events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage
those who might benefit from such treatment from seeking it.
Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to
classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract
employment, or eligibility for physical or logical access to federally controlled facilities or information systems. Seeking
or receiving mental health care for personal wellness and recovery may contribute favorably to decisions about your
eligibility.
Has a court or administrative agency EVER issued an order declaring you mentally incompetent?
Yes: { } No: { x }
Has a court or administrative agency EVER ordered you to consult with a mental health professional (for example,
a psychiatrist, psychologist, licensed clinical social worker, etc.)? (An order to a military member by a superior officer
is not within the scope of this question, and therefore would not require an affirmative response. An order by a military
court would be within the scope of the question and would require an affirmative response.)
Yes: { } No: { x }
Have you EVER been hospitalized for a mental health condition?

Yes: { } No: { x }
The following question asks whether you have been diagnosed with a specified mental health condition that may,
particularly if untreated, impact your judgment, reliability, or trustworthiness. If you answer in the affirmative, we will
seek additional information about the seriousness and symptoms of the condition, as well as any applicable course
of treatment. It is important to note that any such diagnosis, in and of itself, is not a reason to revoke or deny
eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain
Federal or contract employment, or eligibility for physical or logical access to federally controlled facilities or information
systems.
Have you EVER been diagnosed by a physician or other health professional (for example, a psychiatrist, psychologist,
licensed clinical social worker, or nurse practitioner) with psychotic disorder, schizophrenia, schizoaffective disorder,
delusional disorder, bipolar mood disorder, borderline personality disorder, or antisocial personality disorder?
Yes: { } No: { x }
Adversely Affected
Do you have a mental health or other health condition that substantially adversely affects your judgment, reliability,
or trustworthiness even if you are not experiencing such symptoms today?
Yes: { } No: { x }
Note: If your judgment, reliability, or trustworthiness is not substantially adversely affected by a mental health or
other condition, then you should answer "no" even if you have a mental health or other condition requiring treatment.

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For example, if you are in need of emotional or mental health counseling as a result of service as a first responder,
service in a military combat environment, having been sexually assaulted or a victim of domestic violence, or marital
issues, but your judgment, reliability or trustworthiness is not substantially adversely affected, then answer "no."
Section 22 - 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.
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.)
• 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, convicted, or sentenced of 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?
Yes: { } No: { x }
Other than those offenses already listed, have you EVER had the following happen to you?
• Have you EVER been convicted in any court of the United States of a crime, sentenced to imprisonment for a
term exceeding 1 year for that crime, and incarcerated as a result of that sentence for not less than 1 year?
(Include all qualifying convictions in Federal, state, local, or military court, even if previously listed on this form)
• Have you EVER been charged with any felony offense? (Include those under the Uniform Code of Military
Justice and non-military/civilian felony offenses)
• 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?
• Have you EVER been charged with an offense involving firearms or explosives?
• Have you EVER been charged with an offense involving alcohol or drugs?
Yes: { } No: { x }
Is there currently a domestic violence protective order or restraining order issued against you?
Yes: { } No: { x }
Section 23 - Illegal Use of Drugs or Drug Activity

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 in accordance with Federal laws, even though permissible under state laws.

Data Hash Code:
In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or controlled
substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug
or controlled substance.
Yes: { } No: { x }
In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation, trafficking,
production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?
Yes: { } No: { x }
Have you EVER illegally used or otherwise been illegally involved with a drug or controlled substance while
possessing a security clearance other than previously listed?
Yes: { } No: { x }
Have you EVER 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?
Yes: { } No: { x }
In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of whether
or not the drugs were prescribed for you or someone else?
Yes: { } No: { x }
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of
drugs or controlled substances?
Yes: { } No: { x }
Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance?
Yes: { } No: { x }
Section 24 - Use of Alcohol
In the last seven (7) years has your use of alcohol 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?
Yes: { } No: { x }
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol?
Yes: { } No: { x }
Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
Yes: { } No: { x }

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Have you EVER received counseling or treatment as a result of your use of alcohol in addition to what you have
already listed on this form?
Yes: { } No: { x }
Section 25 - Investigations and Clearance Record
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a
security clearance eligibility/access?
Yes: { } No: { x }
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.)
Yes: { } No: { x }
Have you EVER been debarred from government employment?

Yes: { } No: { x }
Section 26 - Financial Record
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
Yes: { } No: { x }
Have you EVER experienced financial problems due to gambling?

Yes: { } No: { x }
In the last seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or
ordinance?
Yes: { } No: { x }
In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement
for a travel or credit card provided by your employer?
Yes: { } No: { x }
Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve
your financial difficulties?
Yes: { } No: { x }
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)
• In the last seven (7) years, you have been 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).

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• 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).
Yes: { } No: { x }
Other than previously listed, have any of the following happened?

• 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, 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 your wages, benefits, or assets garnished or attached for any reason?
• In the last seven (7) years, you have been 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)
Yes: { } No: { x }
Section 27 - 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.
In the last seven (7) years have you illegally or without proper authorization accessed or attempted to access any
information technology system?
Yes: { } No: { x }
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?
Yes: { } No: { x }
In the last seven (7) years have you 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?
Yes: { } No: { x }

Data Hash Code:
Section 28 - Non-Criminal Court Actions
In the last ten (10) years, have you been a party to any public record civil court action not listed elsewhere on this
form?
Yes: { } No: { x }
Section 29 - 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.
Are you now or have you EVER 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?
Yes: { } No: { x }
Have you EVER knowingly engaged in any acts of terrorism?

Yes: { } No: { x }
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?
Yes: { } No: { x }
Have you 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?
Yes: { } No: { x }
Have you EVER 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 any state of the United
States with the specific intent to further such action?
Yes: { } No: { x }
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?
Yes: { } No: { x }
Have you EVER associated with anyone involved in activities to further terrorism?
Yes: { } No: { x }
Additional Comments
Use the space below to continue answers to all other items and to provide any information you would like to add.
Before each answer, identify the number of the item.
Data Hash Code:
Additional Comments
Field is blank!
Note: If you do not have any additional comments to provide, click "Save" to continue.

Data Hash Code:

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National Background Investigation Services (NBIS) Page 1 of 27

Investigation Request #24261BARN0808075 for Applicant SSN 232-35-7488 Archival Copy

National Background Investigation Services (NBIS)

This Investigation Request contains the following documents:

Page 1: Investigation Request Cover Sheet - SF86 2020-02

Certified at 2024-09-17 20:17:57.301 PRIVACY ACT INFORMATION

Form Completion Instructions

Questionnaire for National Security Positions

Certified at 2024-09-17 20:17:57.301 PRIVACY ACT INFORMATION

Certified at 2024-09-17 20:17:57.301 PRIVACY ACT INFORMATION

Sections 1-4 - Identifying Information

Provide your date of birth

Provide your place of birth

Section 5 - Other Names Used

Have you used any other names?

Hair color: Brown .

Eye color: Brown .

Male: { x } Box IS Checked! .

Section 7 - Your Contact Information

Work e-mail address: rpb311@gmail.com .

Work telephone number

Mobile/Cell telephone number

Section 8 - U.S. Passport Information

Do you possess a U.S. passport (current or expired)?

Certified at 2024-09-17 20:17:57.301 PRIVACY ACT INFORMATION

Click HERE for U.S. State Department passport help.

I am a naturalized U.S. citizen.: { } Box NOT Checked! .

I am a derived U.S. citizen.: { } Box NOT Checked! .

I am not a U.S. citizen.: { } Box NOT Checked! .

Section 10 - Dual/Multiple Citizenship Information

Do you now or have you EVER held dual/multiple citizenships?

Section 11 - Where You Have Lived

1. Enter residence information.

Is/was this residence

Rented or leased by you: { } Box NOT Checked! .

Military housing: { } Box NOT Checked! .

Other (Provide explanation): { } Box NOT Checked! .

Provide the street address

City: SUMMERSVILLE State: WV Country: Zip Code: 26651 . . Field is blank! .

Provide the full name

Provide date of last contact

Provide your relationship to this person (check all that apply)

Friend: { } Box NOT Checked! .

Landlord: { } Box NOT Checked! .

Business associate: { } Box NOT Checked! .

Other (Provide explanation): { x } Box IS Checked! .

Provide the following contact information for this person

Provide street address for this person (including apartment number)

City: SUMMERSVILLE State: WV Country: Zip Code: 26651 . . Field is blank! .

2. Enter residence information.

Is/was this residence

Rented or leased by you: { } Box NOT Checked! .

Military housing: { } Box NOT Checked! .

Other (Provide explanation): { } Box NOT Checked! .

Provide the street address

City: SUMMERSVILLE State: WV Country: Zip Code: 26651 . . Field is blank! .

Do you have an additional residence to report?

Section 12 - Where You Went To School