Fillable Printable Security Clearance Forms - United States
Fillable Printable Security Clearance Forms - United States
Security Clearance Forms - United States
United States Secret Service
Security Clearance Forms
08/2013
Instructions
You are being considered for a position with the United States Secret Service.
Since all Secret Service employees are required to have a Top Secret Security
Clearance, the enclosed background investigation forms are being provided for
your immediate completion.
Once you have been asked by a Secret Service representative to complete this
package, please note the following instructions.
All forms must be typed. If the paper-based version of this package has
been provided to you, and if you are able to complete this package in
electronic format, please call your designated Secret Service point-of-contact
so an Adobe Acrobat-based version of this package can be provided to you.
Ensure that ALL questions are answered or addressed. If a question does
not apply (and it is not a yes/no question), indicate N/A for not applicable.
Do not sign or initial any of the forms unless otherwise indicated. (Your
signatures must be witnessed by Secret Service representatives.)
NAME OF CANDIDATE
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
ACKNOWLEDGMENT OF SECURITY
CLEARANCE REQUIREMENTS
THIS FORM MUST BE SIGNED BY ALL CANDIDATES WHO ARE TO BE APPOINTED ON A CONTINGENCY BASIS.
I understand that I am being considered for
appointment with the U.S. Secret Service
based on a contingent security investigation.
I understand that, if accepted, continued
employment with the U.S. Secret Service is
contingent on the satisfactory completion of a
special security background investigation and,
if the position is considered critical-sensitive,
the granting of a Top Secret clearance.
SIGNATURE OF CANDIDATE
DATE SIGNED
SIGNATURE OF WITNESS
DATE SIGNED
DISTRIBUTION: ORIGINAL - OFFICIAL PERSONNEL FILE CC - SECURITY CLEARANCE DIVISION CC - CANDIDATE
SSF 1871 (2/2003) Page 1 of 1
Declaration for Federal Employment*
Form Approved:
OMB No. 32-0182
("This form may also be used to assess tness for federal contract employment)
Instructions
-
The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your
enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring
process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update
your responses on this form and on other materials submitted during the application process and then to recerti that your answers
are true.
All your answers must be truthful and complete. A false stement on any pa of this declaration or aached forms or shee
may be grounds for not hiring you, or for firing you ar you begin work. Also, you may be punished by a ne or
imprisonment (U.S. Code, title 18, section 1001).
Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11 ").
Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your
completed form for your records.
Privacy Act Statement
The Oice of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of
title 5, U. S. Code. Section 1104 of title 5 allows the Oce of Personnel Management to delegate personnel management functions
to other Federal agencies. If necessa, and usually in conjunction with another form or forms, this form may be used in conducting
an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized ocials
making similar, subsequent determinations.
Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and
birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency
records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information
requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.
ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System
Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations
deciding claims for retirement, insurance, unemployment, or health benefits; oicials in litigation or administrative proceedings where
the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical
repos and studies; ocials of labor organizations recognized by law in conneion with representation of employees; Federal
agencies or other sources requesting information for Federal agencies in conneion with hiring or retaining, security clearance,
security or suitability investigations, classiing jobs, contracting, or issuing licenses, grants, or other benefits; public and private
organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection
Board, the Oce of Special Counsel, the Equal Employment Oppounity Commission, the Federal Labor Relations Authority, the
National Archives and Records Administration, and Congressional oces in connection with their ocial functions; prospective
non-Federal employers concerning tenure of employment, civil service status, length of seice, and the date and nature of action for
separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or
individuals
concerning the home address and other relevant information on those who might have contracted an illness or been
exposed
to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent
children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals
working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an
agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the
employees about fitness-for-duty or agency-filed disability retirement procedures.
Public Burden Statement
Public burden repoing for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15
minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspe of the
collection of information, including suggestions for reducing this burden, to the U.S. Oce of Personnel Management, Reports and
Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this
information, and you are not required to respond, unless this number is displayed.
U.S. Oce of Personnel Management
5 u S.C. 1302.3301.3304.3328 & 8716
Opllonal Form 306
Revised October 2011
Previous editions obsolete and unusable
Declaration for Federal Employment*
Form Approved:
OMS No. 32-0182
("This form may also be used to assess fitness for federal contract employment)
GENERAL INFORMATION
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 Suix. First, Middle, Last, Suix)
•
2, SOCIAL SECURITY NUMBER
•
3a. PLACE OF BIRTH (Include city and state or country)
•
3b. ARE YOU A U.S. CITIZEN?
r
YES r NO (If "NO", provide country of citizenship)
•
4, DATE OF BIRTH (MM I DD I YYYY)
•
5, OTHER NAMES EVER USED (For example, maiden name, nickname, etc) 6. PHONE NUMBERS (Include area codes)
•
•
Selective Seice Re
g
istration
Day •
Night •
If you are a male born aer December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you
must register with the Selective Service System, unless you meet ceain exemptions.
7a. Are you a male born aer December 31, 1959?
r YES
r NO (If "NO", proceed to 8.)
7b. Have you registered with the Selective Service System?
r
YES (If ''YES'', proceed to 8.) r NO (If "NO", proceed to 7c.)
7c. If "NO," describe your reason(s) in item 16.
Military Seice
8. Have you ever served in the United States military?
r
YES (If ''YES'', provide information below) r NO
If you answered "YES," st the branch, dates, and type of discharge for a active duty.
If your only active duty was training in the Reserves or National Guard, answer "NO."
Branch
From (MM/DD
To (MM/DD
Type of Discharge
Back
g
round Information
For all questions, provide all additional requested information under item 16 or on aached sheets. The circumstances of each event
you list will be considered. However, in most cases you can still be considered for Federal jobs.
For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) trac
nes of $300 or less, (2) any violation of law committed before your 16th bihday, (3) any violation of law committed before your 18th bihday if
nally decided in juvenile cou or under a Youth Oender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar
state law, and (5) any conviction for which the record was expunged under Federal or state law.
9.
During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?
r YES
r NO
(Includes felonies, rearms or explosives Violations, misdemeanors, and all other oenses.) "YES," use item 16
to provide the date, explanation of the violation, place of occuence, and the name and address of the police
depament or cou involved.
1
O. Have you been convicted by a milita cou-maial in the past 7 years? (If no mita seice, answer "No.'� If
"YES, " use item 16 to provide the date, explanation of the violation, place of occuence, and the name and
address of the milita authori or cou involved.
r
YES r NO
11. Are you currently under charges for any violation of law? "YES," use item 16 to pvide the date, explanation of
r YES
r NO
the violation, place of occuence, and the name and address of the police depament or cou involved.
12. During the last 5 years, have you been red from any job for any reason, did you quit aer being told that you
r YES
r NO
would be red, did you leave any job by mutual agreement because of speCic problems, or were you debarred
from Federal employment by the Oce of Personnel Management or any other Federal agency? "YES, " use item
16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.
13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment
r YES
r NO
of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such
as student and home mogage loans.) "YES," use item 16 to pvide the pe, length, and amount of the
delinquency or default, and steps that you are taking to coect the eor or pay the debt.
U.S. Ofce of Personnel Management
5 u.s.c. 1302,3301,3304,3328 & 8716
Optional Form
Revised October 2011
Preous editions obsolete and unusable
Declaration for Federal Employment*
(*This form may also be used to assess fitness for federal contract employment)
Additional Questions
14. Do any of your relatives work for the agency or government organization to which you are submitting this form?
(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, rst cousin, nephew, niece,
ther-in-Iaw,mother-in-Iaw, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother,
stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES," use item 16 to provide the
relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relative
wos.
15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military,
Federal civilian, or District of Columbia Government seice?
Continuation Space I A
g
ency Optional Questions
Form Approved:
OMB No. 32-0182
r
YES r NO
r YES r NO
16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with
your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please
answer as instructed (these questions are specic to your position and your agency is authozed to ask them).
Ceifications I Additional Questions
APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any
attached sheets. en this form and all attached materials are accurate, read item 17, and complete 17a.
APPOINTEE: If you are being appointed, carefully review your anSwers on this form and any attached sheets, including any other application
materials that your agency has attached to this form. If any information requires correion to be accurate as of the date you are signing, make
changes On this form or the attachments andlor provide updated information on additional sheets, initialing and dating all changes and additions.
When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.
17. I cei that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment,
including any attached application materials, is true, correct, complete, and made in good faith. I undetand that a false or fraudulent
answer to any question or item on any pa of this declaration or its aachments may be grounds for not hiring me, or for firing
me aer I begin work, and may be punishable by fine or imprisonment. I undetand that any information I give may be investigated
for
purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of
information about my ability and tness for Federal employment by employers, schools, law enforcement agenCies, and other individuals
and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I
undetand
that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of
information, a separate specic release may be needed, and I may be contaed for such a release at a later date.
Appointing Oicer:
17a. Applicant's Signature:
Date _ _
Enter Date AppOintment or Conversion
MM IDD/
(Sign in ink)
17b. Appointee's
Signature:
�
.
-----------
---
(Sign in ink)
Date _ _
18.
Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during
previous
Federal employment may affe your eligibility for life insurance during your new appointment. These questions are asked to help
your personnel oce make a correct determination.
18a. en did you leave your last Federal job?
18b. When you worked for the Federal Government the last time, did you waive Basic Life
Insurance or any type of optional life insurance?
MM/DD/YVYY
DATE:
r YES r NO r DO NOT KNOW
18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your anSwer to item
r YES
r NO
r DO NOT KNOW
18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not
canceled.
U.S. Oce of Personnel Management
5 u.s.c. 1302,3301,3304,3328 & 8716
OpHonai Form
Revised October 2011
Previous editions obsolete and unusable
Depending upon the purpose of your investigation, the U.S. Government is
authorized to ask for this information under Executive Orders 10450, 10865,
12333, and 12968; sections 3301, 3302, and 9101 of title 5, United States
Code (U.S.C.); sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title
50, U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal
Regulations (CFR).
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.
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 732, 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 .
This form is 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.
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.
Purpose of this Form
Authority to Request this Information
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.
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.
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. If you have a
security freeze on your consumer or credit report file, then we may not be
able to complete your investigation, which can adversely affect your eligibility
for a national security position. To avoid such delays, you should request that
the consumer reporting agencies lift the freeze in these instances.
The Investigative Process
In addition to the questions on this form, inquiry also is made about your
adherence to security requirements, 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, 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.
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 documents; (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.
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 immediately 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.
Your Personal Interview
Instructions for Completing this Form
2.
3.
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.
Type or legibly print your answers in ink. If the form is not legible, it will
not be accepted. You may also be asked to submit your form using the
approved electronic format.
All questions on this form must be answered. If no response is
necessary or applicable, indicate this on the form with "N/A," unless
otherwise noted.
Any changes that you make to this form, after you sign it, must be
initialed and dated by you. Under extremely limited circumstances,
agencies may modify your response(s) with your consent.
4.
5. You must use the Location codes (abbreviations), immediately following
the Privacy Act Routine Uses, when you fill out this form. Do not
abbreviate the names of cities or foreign countries.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
6. Place of birth requires Country entry, even if in the U.S.
To the Office of Management and Budget when necessary to the review of
private relief legislation.
7.
9.
10.
8.
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.
For telephone numbers in the U.S., ensure that the area code is included.
All dates provided in this form must be in Month/Day/Year or Month/Year
format. Use numbers (01-12) to indicate months. For example, July 29,
1968, should be written as 07/29/1968. If you are unable to report an
exact date, approximate or estimate the date to the best of your ability,
and indicate "APPROX." or "EST" in the field.
If additional space is required for an explanation or to list your residences,
employment/self- employment/unemployment, or education, you should
use a continuation sheet, SF 86A, located at http://www.opm.gov/forms,
select standard forms. If additional space is required to answer other
items, use the Continuation Space, on page 121, or a blank sheet(s) of
paper. Include your name and SSN at the top of each blank sheet (s)
used.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
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.
Penalties for Inaccurate or False Statements
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. The office that gave you this form will provide you a
copy of its routine uses.
Disclosure Information
Privacy Act Routine Uses
2.
3.
4.
5.
6.
7.
9.
10.
8.
1. To the Department of Justice when: (a) the agency or any component
thereof; or (b) any employee of the agency in his or her official capacity; or
(c) any employee of the agency in his or her individual capacity where the
Department of Justice has agreed to represent the employee; or (d) the
United States Government, is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records
are both relevant and necessary to the litigation and the use of such
To a court or adjudicative body in a proceeding when: (a) the agency or
any component thereof; or (b) any employee of the agency in his or her
official capacity; or (c) any employee of the agency in his or her individual
capacity where the Department of Justice has agreed to represent the
employee; or (d) the United States Government is a party to litigation or
has interest in such litigation, and by careful review, the agency
determines that the records are both relevant and necessary to the
litigation and the use of such records is therefore deemed by the agency
to be for a purpose that is compatible with the purpose for which the
agency collected the records.
Except as noted in Sections 23 and 27, when a record on its face, or in
conjunction with other records, indicates a violation or potential violation of
law, whether civil, criminal, or regulatory in nature, and whether arising by
general statute, particular program statute, regulation, rule, or order issued
pursuant thereto, the relevant records may be disclosed to the appropriate
Federal, foreign, State, local, tribal, or other public authority responsible for
enforcing, investigating or prosecuting such violation or charged with
enforcing or implementing the statute, rule, regulation, or order.
To any source or potential source from which information is requested in the
course of an investigation concerning the hiring or retention of an employee
or other personnel action, or the issuing or retention of a security clearance,
contract, grant, license, or other benefit, to the extent necessary to identify
the individual, inform the source of the nature and purpose of the
investigation, and to identify the type of information requested.
To a Federal, State, local, foreign, tribal, or other public authority the fact
that this system of records contains information relevant to the retention of
an employee, or the retention of a security clearance, contract, license,
grant, or other benefit. The other agency or licensing organization may
then make a request supported by written consent of the individual for the
entire record if it so chooses. No disclosure will be made unless the
information has been determined to be sufficiently reliable to support a
referral to another office within the agency or to another Federal agency
for criminal, civil, administrative, personnel, or regulatory action.
To contractors, grantees, experts, consultants, or volunteers when
necessary to perform a function or service related to this record for which
they have been engaged. Such recipients shall be required to comply with
the Privacy Act of 1974, as amended.
To the news media or the general public, factual information the disclosure
of which would be in the public interest and which would not constitute an
unwarranted invasion of personal privacy.
To a Member of Congress or to a Congressional staff member in response
to an inquiry of the Congressional office made at the written request of the
constituent about whom the record is maintained.
To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
To a Federal, State, or local agency, or other appropriate entities or
individuals, or through established liaison channels to selected foreign
governments, in order to enable an intelligence agency to carry out its
responsibilities under the National Security Act of 1947 as amended, the
CIA Act of 1949 as amended, Executive Order 12333 or any successor
order, applicable national security directives, or classified implementing
procedures approved by the Attorney General and promulgated pursuant
to such statutes, orders or directives.
11.
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 race, color, religion, sex, national origin,
disability, or sexual orientation when granting access to classified information.
Final Determination on Your Eligibility
records by the Department of Justice is therefore deemed by the agency
to be for a purpose that is compatible with the purpose for which the
agency collected the records.
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,
Federal Investigative Services, Attn: OMB Number 3206-0005, 1900 E. Street N.W., Washington, DC 20415. Do not send your completed form to this address;
send it to the office that provided you the form. 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.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
LOCATION CODES
PUBLIC BURDEN INFORMATION
South Dakota SD
Tennessee TN
Texas TX
Utah UT
Vermont VT
Virginia VA
Washington WA
West Virginia WV
Wisconsin WI
Wyoming WY
Wake Island WQ
APO/FPO America AA
APO/FPO Europe AE
APO/FPO Pacific AP
New Mexico NM
New York NY
North Carolina NC
North Dakota ND
Ohio OH
Oklahoma OK
Oregon OR
Pennsylvania PA
Rhode Island RI
South Carolina SC
Palmyra Atoll LQ
Puerto Rico PR
Virgin Islands, United VI
States
Massachusetts MA
Michigan MI
Minnesota MN
Mississippi MS
Missouri MO
Montana MT
Nebraska NE
Nevada NV
New Hampshire NH
New Jersey NJ
Midway Islands MQ
Navassa Island BQ
Northern Mariana Islands
MP
Palau PW
Hawaii HI
Idaho ID
Illinois IL
Indiana IN
Iowa IA
Kansas KS
Kentucky KY
Louisiana LA
Maine ME
Maryland MD
Johnson Atoll JQ
Kingman Reef KQ
Marshall Islands MH
Micronesia, Federated FM
States
Alabama AL
Alaska AK
Arizona AZ
Arkansas AR
California CA
Colorado CO
Connecticut CT
Delaware DE
District of Columbia DC
Florida FL
Georgia GA
American Samoa AS
Baker Island FQ
Guam GU
Howland Island HQ
Jarvis Island DQ
V Applicant affiliation
None
J SON
(Submitting Office Number)
Initial
Reinvestigation
S Investigative requirement
Investigating agency user only
Codes: (FIPC CODES)
Case Number:
P Obligating document number Q Business Event Type Code
R Accounting data and/or Agency case number
T Requesting official - Name
Title Signature
Title
Telephone number
(Include Ext.)
FED CIV
CON
Other
Other address/Web address of e-OPF
Zip Code
A Type of investigation
C Sensitivity level Compu/ADP D Access/Eligibility E Nature of action code
G Geographic location
H Position code I Position title
K Location of official personnel folder
U Secondary requesting official - Name
B Extra coverage/Advance results
NPRC
At SON
e-OPF
Other
L SOI (Security Office Identifier) M Location of security folder
None
NPI
At SOI
Other
Other address
Email address
Email address Telephone number (Include Ext.) Date (Month/Day/Year)
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.
Zip Code
MIL
N IPAC
O Treasury Account Symbol
AGENCY USE BLOCK "AUB"
W Deployment/PCS - (Do not provide deployment data if Classified or Sensitive information)
Point of contact at location Address/Unit/Duty location (Include City or Post Name)
Commercial and Government Entity (CAGE) Code Contract Number
F Date of action (Month/Day/Year)
Agency Special Instructions for the Investigative Service Provider.
Reason(s) for temporary duty assignment or PCSFrom (Month/Day/Year)
Location
(if imminent)
Telephone number (Include Ext.)
Est.
Permanent Relocation
Est. To
(Month/Day/Year)
Page 1
Provide your other name(s) used and the period of time you used it/them [for example: your maiden name(s), 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.
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
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.
Enter your Social Security Number before going to the next page
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#1
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Section 5 - Other Names Used
Section 3 - Place of Birth
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.
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING
THE PRECEDING INSTRUCTIONS.
YES NO
Provide your place of birth.
Last name
First name
Middle name
City
County
Country (Required)
State
YES NO (If NO, proceed to Section 6)
Have you used any other names?
Not applicable
Provide your U.S. Social Security Number.
Section 4 - Social Security Number
Male
Female
Sex
Section 6 - Your Identifying Information
Weight
(in pounds) Hair color Eye color
Provide your identifying information.
Suffix
(feet) (inches)
Height
Section 2 - Date of Birth
Section 1 - Full Name
Provide your date of birth.
(Month/Day/Year)
Complete the following if you have responded 'Yes' to having used other names.
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#2
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#3
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#4
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Page 2
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
The following link will provide U.S. State Department
passport help. http://travel.state.gov/passport
Issue date Expiration date
Est.
Provide the name in which passport was first issued.
Middle name
Last name
First 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.
(Proceed to Section 10)
I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.
(Complete 9.1)
I am not a U.S. citizen. (Complete 9.3)
I am a naturalized U.S. citizen. (Complete 9.2)
Provide document number for U.S. citizen born abroad.
Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)
Country
State
City
Provide the name in which document was issued.
Middle name
Last name
First name
Suffix
Provide the address of the court that issued the citizenship certificate.
Provide the name in which the certificate was issued.
Middle name
Last name
First name
Suffix
Were you born on a U.S. military installation?
YES NO (If NO, proceed to Section 10)
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Est.
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 the date the document was issued.
(Month/Day/Year)
Est.
Provide your citizenship certificate number.
Provide the date the certificate was issued. (Month/Day/Year)
Est.
Provide type of documentation of U.S. citizen born abroad.
FS240 or FS545 DS 1350 Other (Provide explanation)
(Month/Day/Year) (Month/Day/Year)
Section 7 - Your Contact Information
Provide your contact information.
Home e-mail address Work e-mail address
Home telephone number
Extension
International or DSN phone number
Night
Day
Work telephone number
Extension
International or DSN phone number
Night
Day
Mobile/Cell telephone number
Extension
International or DSN phone number
Night
Day
Provide the name of the court that issued the citizenship certificate.
State
City
Street
Zip Code
Provide the name of the base.
