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Fillable Printable SF 86C

Fillable Printable SF 86C

SF 86C

SF 86C

Standard Form 86C
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
STANDARD FORM 86 CERTIFICATION
(SF 86C)
Form approved:
OMB No. 3206 0005
NSN 7540-01-500-4881
86-111
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on page 2. If you have any questions, contact the office that gave you
this form.
The Standard Form 86 (SF 86), Questionnaire for National Security Positions, is completed by persons under consideration for or retention in national security positions as
defined in 5 CFR 732 and for positions requiring access to classified information, as defined in Executive Order 12968. Depending upon the purpose of your investigation, the
United States (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, U.S.
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.
There are many situations where individuals are required to fill out a new SF 86 when the sole purpose is to determine if any information on a previously executed SF 86 has
changed. This requires extensive work by the individual even if nothing has changed. The SF 86C is a certification document that allows the reporting of changes in previously
reported information on the SF 86. This certification will be in lieu of completing a new SF 86 and will allow the individual to indicate that there have been no changes in the data
provided on the most recently filed SF 86 or it will allow the individual to easily provide new or changed information. No investigation will be initiated based solely on the
execution of this form.
Your Social Security Number (SSN) is needed to identify your unique records. 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.
PRIVACY ACT ROUTINE USES
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 dividual 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 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.
2. 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.
3. Except as noted in Question 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.
4. 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 etention 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.
8. 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.
7. 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.
6. 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.
5. 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.
9. 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.
10. To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
11. To the Office of Management and Budget when necessary to the
review of private relief legislation.
PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information averages 15 minutes, 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 OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street NW, 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.
Standard Form 86C
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
STANDARD FORM 86 CERTIFICATION
(SF 86C)
Form approved:
OMB No. 3206 0005
NSN 7540-01-500-4881
86-111
INSTRUCTIONS: Type or legibly print your answers in ink (if this form is not legible, it will not be accepted). Complete this form referencing
information contained in your most recent SF 86 or information disclosed upon the date of your last background investigation. All questions
on this form must be answered. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain
limited circumstances, agencies may modify your response(s) consistent with your intent. The United States 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 5 years of
imprisonment.
Do not provide information you have already provided on your most recent SF 86. Any "Yes" responses under Block 2 must be
explained in Block 3. If additional space is needed, use a blank sheet of paper. Each blank sheet of paper you use must contain your
name and SSN at the top of the page. Conclude by certifying the accuracy of your answers in Block 4, Certification. If you have any
questions, contact the office that gave you the form, or a Government security officer.
INSTRUCTIONS: The following Questions correlate with your SF 86. If you report no change to a Question, place an "X" in the No box.
If there is a change , place an "X" in the Yes box. All Yes answers must be explained under Block 3, Explanations/Remarks.
Page 1
Block 2 – Questions from the SF 86
Block 1 - Identification
Full name (last,first,middle,maiden)Social Security Number (SSN)
Date of birth (mm/dd/yyyy)Place of birth (include City (Country) and State)
Work telephone number
Home telephone number
E-mail
Question 1. Full Name
Question 4. Social Security Number
Question 5. Other Names Used
Question 9. Citizenship
Question 10. Citizenship Information
Question 12. Where You Went to School
Question 11. Where You Have Lived
Question 13. Employment Activities
Question 14. Selective Service Record
Question 15. Military History
Question 17. Marital Status
Question 19. Foreign Contacts
Question 18. Relatives
Question 20. Foreign Activities
Question 21. Mental and Emotional Health
Question 23. Use of Illegal Drugs and Drug Activity
Question 22. Police Record
Question 24. Use of Alcohol
Question 25. Investigations and Clearance Record
Question 27. Use of Information Technology Systems
Question 26. Financial Record
Question 28. Involvement in Non-Criminal Court Actions
Question 29. Association Record
YesNo
Standard Form 86C
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
STANDARD FORM 86 CERTIFICATION
(SF 86C)
Form approved:
OMB No. 3206 0005
NSN 7540-01-500-4881
86-111
Block 4 – Certification
I certify that the above information includes all changes to my most recent SF 86 or since my last investigation. Changes, if any, are
explained under Block 3. My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my
knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished
by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information will
have a negative affect on my security clearance, employment prospects, or job status up to and including denial or revocation of my
security clearance, or my removal and debarment from Federal service.
Signature (SigninInk)
Date
(mm/dd/yyyy)
Page 2
Check this block if additional comments are attached. Place your name and SSN at the top of each page.
Check this block if your SF 86 is attached.
INSTRUCTIONS: Before each answer, identify the SF 86 Question number associated with your answer. For example, if you have had
a change of residence, write "Question 11" and list your new address.
Block 3 – Explanations/Remarks
Enter your Social Security Number before going to the next page
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