Fillable Printable 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

Yes No

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 (Sign in Ink)

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