Fillable Additional Questions For Moderate Risk Positions (Social Security Administration)

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Additional Questions For Moderate Risk Positions (Social Security Administration)

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Additional Questions for Public Trust Positions - Branching
INSTRUCTIONS
This form is a supplement to the Standard Form 85P, Questionnaire for Public Trust Positions, currently in use in NBIB automated systems. Use
of this form in addition to the
e-QIP SF85P equates to the SF85P approved by OMB
in October 2017.
This is an interim collection method until
such time the SF85P is updated in e-QIP.
IDENTIFICATION INFORMATION
1 - FULL NAME:
Enter your name as it appears on your SF 85P, Questionnaire for Public Trust Positions.
Last Name
First Name
Middle
Name
Jr., II, etc.
2 - NBIB CASE NUMBER: If applicable.
PUBLIC TRUST QUESTIONS
3 - EDUCATION: Have you received a degree more than seven
(7)
years ago? If YES,
provide details in section 3A.
Yes No
3A – Education Details
Dates of Attendance
FROM:
TO:
(MM/YY Month and Year)
Choose Type of
Qualification
Degree
Other
If other please provide:
Date Awarded
MONTH:
Y
EAR:
Choose the most appropriate
characterization of the school
College/University/Military
College
Vocational/Technical/Trade
School
Correspondence/Distance/
Extension/Online School
Name of School
Street Address of School City
State
Zip
code
Use the c
ontinuation sheet on the back if you have more than one degree earned more than 7 years ago.
For each Yes response on questions 4 through 30, corresponding branching questions starting
on page 5 must be completed.
Yes/No Questions Yes No
4 – Have you EVER been issued a passport (or identity card for travel) by a country other
than the U.S.?
5 – 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 violation of
a security policy?
6 – In the last seven (7) years, have you been subject to court martial or other disciplinary
procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s
Mast, Article 135 Court of Inquiry, etc.? (If no prior military service, answer “No”.)
7 – 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?
8 – 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 former legally
recognized civil union/domestic partner, or someone with whom you share a child in
common?
CLEAR FORM
9 –
Is
there currently a domestic violence protective order or
restraining order
issued a
gainst
you?
10 –
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.
11 – 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?
12 – In the last seven (7) years, have you 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?
13 –
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 Questions
Yes No
14 –
In the last seven (7) years, have you been ordered, advised, or asked to seek
counseling or
treatment
as a result of
your illegal
use of drugs or controlled substances?
15 – In the last seven (7) years, have you voluntarily sought counseling or treatment as a
result of your use of a drug or controlled substance?
16 – In the last seven (7) years, have you filed
a petition under any chapter of the
bankruptcy code?
17 – In the last seven (7) years, have you failed to meet financial obligations due to
gambling?
18 – In the past seven (7) years, have you failed to file or pay Federal, state or other taxes
when required by law or ordinance?
19 – In the past seven (7) years, have you been over 120 days delinquent on any debt?
(Include financial obligations for which you were the sole debtor, as well as those for which
you were a cosigner or guarantor.)
20 – In the last seven (7) years, has your use of alcohol had a negative impact on your work
performance, your professional relationships, or resulted in intervention by law
enforcement/public safety personnel?
21 – In the last seven (7) years, have you illegally or without proper authorization
accessed or
attempted to access any information technology system?
Yes/No Questions
Yes No
22 – 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 attem
pted any of the above? (Above refers to the actions listed in this
question)
23 – 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? (Above refers to the actions listed in this question)
24 – Are you now or hav
e you EVER been
a member of an organization dedicated to
t
er
r
or
i
sm
,
eit
her
wi
t
h an
aw
ar
eness
of
t
he o
r
g
ani
z
at
i
on’
s
dedica
t
i
on to
t
ha
t
end,
or
wi
t
h
t
he
sp
eci
f
ic i
nt
en
t
to
f
urther such activities?
25 – Have you EVER knowingly engaged in any acts of terrorism?
26 – Have you EVER advocated any acts of terrorism or activities designed to overthrow
the U.S. Government by force?
27 – Have you EVER been a member of an organization dedicated to the use of violence
or force t
o overthrow the U.S. 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?
28 – 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?
29 – Have you EVER knowingly engaged in activities designed to overthrow the
U.S. Governmen
t by force?
30 – Have you EVER associated with anyone involved in activities to further terrorism?
CERTIFICATION
Certification That My Answers Are True
My statements on this form, and 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. (See section 1001 of title 18, United States Code).
Date Signature
click to sign
signature
click to edit
Question 4
4a. Country in which the passport (or identity card ) was issued
4b. Date the passport (or identity card) was issued
4c. Place the passport (or identity card) was issued (City and Country)
4d. Full Name under which passport (or identity card) was issued
4e. Passport (or identity card) Number
4f. Passport (or identity card) expiration date
4g. What is the reason for the foreign passport (or identity card)?
Yes No
4h. Have you ever used this passport (or identity card) for foreign travel?
4i. Countries to which you have traveled on this passport (or identity card) and the dates involved with each
4j. Do you have an additional foreign passport (or identity card)?
If yes, please use the continuation sheet on page 20 to provide the information
Question 5
5a. Date of incident (Month/Year)
5b. Reason/details
5c. Location of incident (Street address, City, State, Zip Code or Country)
5d. Final outcome/result
5e. Date of outcome/result (Month/Year)
Country From To
Country From To
Country From To
Country From To
Country From To
Country From To
Yes No
5f. Do you have other incidents to report?
Yes
No
Estimated
Estimated
If yes, please use the continuation sheet on page 20 to provide the information
Return to Page 1
Return to Page 1
Question 6
6a. Date of the court martial or other disciplinary procedure
(month/year)
6b. Description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you were charged
6c. Name of the disciplinary procedure, such as court martial, Article15, Captains Mast, Article 135 Court of inquiry, etc...
6d. Description of the military court or other authority in which you were charged (title of court
or convening authority, address, to include city and state or country if overseas)
6e. Description of the final outcome of the disciplinary procedure, such as found guilty, found not
guilty, fine, reduction of rank, imprisonment, etc.
6f. Do you have other instances of military discipline in the last seven years?
Yes
No
If yes, please use the continuation sheet on page 20 to provide the information
Question 7
7a. During your foreign service, which organization were you serving under:
Intelligence Service
Military (Army, Navy, Air Force, Marines, etc.
Diplomatic Service
Militia
Security Forces
Other Defense Forces (Specify)
Other Government Agency (Specify)
If other Government Agency or Defense Forces, please specify
7b. Name of the foreign organization
7c. Period of Service (Estimated)
7d. Name of Country Served
7e. Highest position/rank held
7f. Division/department/office in which you served
7g. Describe the circumstances of your association with this organization
7h. Describe reason for leaving this service
7i. Do you have further foreign service?
Yes
No
If yes, please use the continuation sheet on page 20 to provide the information
Estimated
Return to Page 1
Return to Page 1
Question 8
8a. Date of the offense (Month/Year) Estimated
8b. Describe the nature of the offense
8c. Name of the court
8d. Court location (Street address, City, State, Zip Code or Country
8e. Provide all charges brought against you for this offense, and the outcome of each charged offense (such as
found guilty, found not guilty, or charge dropped or "nolle pros," etc.). If you were found guilty of or plead guilty to a
lesser offense, list both the original charge and the lesser offense separately.
8f.
Felony/Misdemeanor/Other?
8g. What was the charge
8h.
Date of the outcome (Month/Year)
8i. Were you sentenced as a result of these charges?
Yes
No
1.
If yes, describe the sentence
2.
Were you sentenced to imprisonment for a term exceeding one year?
No
3.
Were you incarcerated as a result of that sentence for not less than 1 year?
Yes
No
4.
If the conviction resulted in
imprisonment, provide the dates that
you were incarcerated
From
To
8j. If no to being sentenced, are you currently on trial, awaiting trial, or awaiting sentencing on
criminal charges for this offense? Explain
8k. Do you have any other offenses?
If yes, please use the continuation sheet on page 20 to provide
information Question 9
9a. Date the order was issued Estimated
9b. Name of the court or agency that issued the order.
9c. Location of court or agency that issued the order (Street address, City, State, Zip Code, Country)
9d. Do you have any other domestic violence protective orders or restraining
orders currently issued against you? Yes
No
Yes
No
Yes
If yes, please use the continuation sheet on page 20 to provide information
Return to Page 2
Return to Page 2
Estimated
Question 10
10a. Type of drug or controlled substance:
Cocaine or crack cocaine (Such as rock, freebase, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Depressants (Such as barbituates, methaqualone, tranquilizers, etc)
Ketamine (Such as special K, jet, etc)
Narcotics (Such as opium, morphine, codeine, heroine, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.)
Other (Provide Explanation)
10b. Estimate month and year of first use Estimated
10c. Estimate month and year of most recent use
10d. Nature of use, frequency and number of times used
10e. Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom
official, or while in a position directly and immediately affecting public safety?
Yes
No
10f. Was your use while possessing a security clearance?
Yes
No
10g. Do you intend to use this drug or controlled substance in the future?
Yes
No
10h.
Explain why you intend or do not intend to use this drug or controlled substance in the future.
Yes
No
10i. Do you have an additional instance(s) of illegal use of a drug or controlled substance?
If yes, please use the continuation sheet on page 20 to provide information
Question 11
11a. Type of drug or controlled substance:
Cocaine or crack cocaine (Such as rock, freebase, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Depressants (Such as barbituates, methaqualone, tranquilizers, etc)
Ketamine (Such as special K, jet, etc)
Narcotics (Such as opium, morphine, codeine, heroine, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.)
Other (Provide Explanation)
11b. Estimate month and year of first involvement
11c. Estimate month and year of most recent involvement Estimated
Estimated
Return to Page 2
11d. Nature of involvement and frequency
11e. Reason for engagement in the activity
11f. Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom
official, or while in a position directly and immediately affecting public safety?
Yes
No
11g. Was your involvement while possessing a security clearance?
Yes No
11h. Do you intend to be involved with this drug or controlled substance in the future?
Yes
No
11i. Explain why you intend or do not intend to be involved with this drug or controlled substance in the future
11j. Do you have an additional instance(s) of illegal involvement with any drug or controlled substance?
If yes, please use the continuation sheet on page 20 to provide information
Yes No
Question 12
12a. Describe the drugs or controlled substances used and your involvement
12b. Dates of involvement From To Estimated
12c. Estimate the number of times you used and/or were involved with this drug or controlled substance
while employed in this capacity
12d. Do you have an additional instance(s) of illegal use or involvement 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? Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 13
13a. Name of the prescription drug that you misused
13b. Dates of involvement From To Estimated
13c. Reason(s) for and circumstances of the misuse of the prescription drug
Return to Page 2
Return to Page 2
13d. Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom
official, or while in a position directly and immediately affecting the public safety?
Yes
No
13e. Was your involvement while possessing a security clearance? Yes No
13f. Do you have additional instance(s) of intentionally engaging in the misuse of prescription
drugs in the last seven (7) years?
Yes
No
If yes, please use the continuation sheet on page 20 to provide information
Question 14
14a. Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of
your illegal use of drugs or controlled substances?
An employer, military commander, or employee assistance program
A medical professional
A mental health professional
A court official/judge
14b. If you have not been ordered, advised, or asked to seek counseling or treatment by one of partie
already mentioned, explain
s
14c. Did you take action to receive counseling or treatment?
Yes No
1. If no, explain
2. If yes, type of drug or controlled substance for which you were treated:
A. Type of drug or controlled substance for which you were treated:
Cocaine or crack cocaine (Such as rock, freebase, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Depressants (Such as barbituates, methaqualone, tranquilizers, etc)
Ketamine (Such as special K, jet, etc)
Narcotics (Such as opium, morphine, codeine, heroine, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.)
Other (Provide Explanation)
B. Name of the treatment provider (Last name, First Name)
C. Address for the treatment provider (address, City, State, Zip Code, or Country )
Return to Page 2
D. Phone Number of the treatment provider
E. Dates of Treatment From To
Estimated
F. Did you successfully complete the treatment?
Yes
No
1.
If no, explain?
14d. Do you have any other instances of having been ordered, advised, or asked to seek drug or
controlled substance counseling or treatment in the last seven (7) years? Yes No
If yes, please us the continuation sheet on page 20 to provide information
Question 15
15a. Type of drug or controlled substance for which you were treated:
Cocaine or crack cocaine (Such as rock, freebase, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Depressants (Such as barbituates, methaqualone, tranquilizers, etc)
Ketamine (Such as special K, jet, etc)
Narcotics (Such as opium, morphine, codeine, heroine, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.)
Other (Provide Explanation)
15b. Name of the treatment provider (Last name, First name)
15c. Address for the treatment provider (address, City, State, Zip Code, or Country )
15d. Phone Number of the treatment provider
15e. Dates of Treatment From To Estimated
15f. Did you successfully complete the treatment?
Yes
No
If no, explain?
15g. Do you have any other instances of ever voluntarily seeking counseling or treatment as a result
of your use of a drug or controlled substance? Yes No
If yes, please use the continuation sheet on page 20 to provide information
Return to Page 2
Return to Page 2
Question 16
16a. Type of bankrupcy petition:
Chapter 7
Chapter 11 Chapter 12 Chapter 13
1. If Chapter 12 or 13, provide: Name of Trustee
2. Address of Trustee (Street address, City, State, Zip Code or Country)
16b. Bankrupcy court docket/account number
16c. Date bankrupcy was filed
Estimated
16d. Date of bankrupcy discharge
Estimated
16e. Total amount (in U.S. dollars) involved in the bankrupcy
Estimated
16f. Name debt is recorded under (Last, First, Middle, Suffix)
16g. Name of court involved
16h. Address of court involved (Street address, City, State, Zip Code or Country)
16i. Were you discharged of all debts claimed in the bankrupcy? Explain
16j. In the past seven (7) years, have you filed any additional petitions under any chapter of the bankrupcy
code? Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 17
17a. Date range of your financial problems due to gambling From
To Estimated
17b. Estimate the amount (in U.S. dollars) of gambling losses incurred
17c. Describe your financial problems due to gambling
17d. If you have taken any action(s) to rectify your financial problems due to gambling, describe
your actions. If you have not taken any action(s), explain
Return to Page 2
17e. In the last seven (7) years, have you failed to meet other financial obligations due to gambling?
Yes
If yes, please use the continuation sheet on page 20 to provide information
Question 18
18a.
Did you fail to file, pay as required, or both?
To file Pay as required
Both
18b. Year you failed to file or pay your federal, state, or other taxes
18c. Reason(s) for your failure to file or pay required taxes
18d. Federal, state or other agency to which you failed to file or pay taxes
18e. Type of taxes you failed to file or pay (such as property, income, sales, etc.)
18f. Amount (in U.S. dollars) of the taxes Estimated
18g. Date satisfied (Estimated), if applcable
18h. Describe any action(s) you have taken to satisfy this debt (such as withholdings, frequency and
amount of payments, etc.) If you have not taken any action(s), explain
18i. Are there any other instances in the past seven (7) years where you failed to file or pay federal,
state or other taxes when required by law or ordinance?
Yes
No
If yes, please use the continuation sheet on page 20 to provide information
Question 19
19a. Loan/account number(s) involved
19b. Identify/describe the type of property involved (if any)
19c. Amount (in U.S. dollars) of the financial issue (Estimated)
19d. Reason(s) for the financial issue
19e. Current status of the financial issue
19f. Date the financial issue began
19g. Date the financial issue was resolved, if applicable
No
Return to Page 2
Return to Page 2
19h. Describe any action(s) you have taken to satisfy this debt (such as withholdings, fequency and
amount of payments, etc.). If you have not taken any action(s), explain
19i. Do you have another delinquent debt of 120 days or more in the last seven(7) years?
Yes
No
If yes, please use the continuation sheet on page 20 to provide information
Question 20
20a. Month/Year when this negative impact occurred Estimated
20b. Explain the circumstances and the negative impact
20c. Dates of involvement or use From
To
Estimated
20d. Has the use of alcohol had any other negative impacts on your work performance, your professional
relationships, or resulted in intervention by law enforcement/public safety personnel?
Yes No
If so, please use the continuation sheet on page 19 to provide information
20e. In the last seven (7) years, have you been ordered, advised, or asked to seek counseling or
treatment as a result of your use of alcohol? Yes No
1. If yes, did you take action to seek counseling or treatment? Yes No
2. If no action taken, please explain
20f. If yes to taking action to seek counseling or treatment
1. Dates of counseling or treatment From
To
Estimated
2. Name of the individual counselor or treatment provider
3. Address of the counseling/treatment provider (Street address, City, State, Zip Code or Country)
4. Telephone number (Number/extension)
5. Did you successfully complete the treatment program? Yes No
6. If no, please explain
Return to Page 2
20g. Do you have additional instances of having been ordered, advised, or asked to seek counseling or
treatment as a result of your use of alcohol? Yes No
If so, please use the continuation sheet on page 20 to provide information
20h. In the last seven (7) years, have you voluntarily sought counseling or treatment as a result of your use
of alcohol? Yes No
1. Dates of counseling or treatment
From To
Estimated
2. Name of the individual counselor or treatment provider
3. Address of the counseling/treatment provider (Street address, City, State, Zip Code or Country)
4. Telephone number (Number/extension)
5. Did you successfully complete the treatment program? Yes No
6. If no, please explain
20i. Do you have additional instances where you have voluntarily sought counseling or
treatment resulting from your use of alcohol? Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 21
21a. Date of the incident (Month/Year)
Estimated
21b. Describe the nature of the incident or offense
21c. Location of the incident (Street address and City, State, Zip Code or Country)
21d. Describe the action (administrative, criminal, or other) taken as a result of this incident
21e. Are there any other incidents?
Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 22
22a. Date of the incident (Month/Year) Estimated
22b. Describe the nature of the incident or offense
Return to Page 2
Return to Page 3
22c. Location of the incident (Street address and City, State, Zip Code or Country)
22d. Describe the action (administrative, criminal, or other) taken as a result of this incident
22e. Are there any other incidents?
Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 2
3
23a. Date of the incident (Month/Year) Estimated
23b. Describe the nature of the incident or offense
23c. Location of the incident (Street address and City, State, Zip Code or Country)
23d. Describe the action (administrative, criminal, or other) taken as a result of this incident
23e. Are there any other incidents?
Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 24
24a. Full name of the organization
24b. Address/location of the organization (Street address, City, State, Zip Code or Country)
24c. Dates of your involvement with the organization
From
To Estimated
24d. All positions held in the organization, if any
24e. All contributions made to the organization, if any
24f. Describe the nature of and reasons for your involvement with the organization
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Return to Page 3
24g. Do you have any other instances of being a member of an organization dedicated to
terrorism, either with an awareness of the organizations dedication to that end, or with
the specific intent to further such activities? Yes
No
If yes, please use the continuation sheet on page 20 to provide information
Question 25
25a. Describe the nature and reasons for the activity
25b. Dates for any such activities From To Estimated
25c. Do you have any other instances of knowingly engaging in acts of terrorism?
Yes
No
If yes, please use the continuation sheet on page 20 to provide information
Question 26
26a.
Reason(s) for advocating acts of terrorism
26b. Dates of advocating acts of terrorism From To Estimated
26c. Do you have any other instances of advocating acts of terrorism or activities designed
to overthrow the U.S. Government by force? Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 27
27a. Full name of the organization
27b. Address/location of the organization (Street address, City, State, Zip Code or Country)
27c. Dates of your involvement with the organization From
To Estimated
27d. All positions held in the organization, if any
27e. All contributions made to the organization, if any
27f. Describe the nature of and reasons for your involvement with the organization
Return to Page 3
Return to Page 3
Return to Page 3
27g. Do you have any other instances of being a member of an organization dedicated to the use
of violence or force to overthrow the U.S. Government, which engaged in activities to that end
with an awareness of the organizations dedication to that end or with the specific intent to further
such activities? Yes No
If yes, please use the continuation sheet on page 20 to provide information
Question 28
28a. Full name of the organization
28b. Address/location of the organization (Street address, City, State, Zip Code or Country)
28c. Dates of your involvement with the organization
From To
28d. All positions held in the organization, if any
28e. All contributions made to the organization, if any
28f. Describe the nature of and reasons for your involvement with the organization
28g. Do you have any other instances of being 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
If yes, please use the continuation sheet on page 20 to provide information
Question 2
9
29a. Describe the nature and reasons for the activity
29b.
Dates of such activities
From
To
Estimated
29c.
Do you have any other instances of having knowingly engaged in activities designed to
overthrow the U.S. government by force?
Yes
No
If yes, please use the continuation sheet on page 20 to provide information
Return to Page 3
Return to Page 3
Return to Page 3
30a. Have you ever associated with anyone involved in activities to further terrorism? Explain
Question 30
Return to Page 3
Continuation sheet
For any questions you have additional information for, please refer to the question number, then provide
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Additional Questions For Moderate Risk Positions (Social Security Administration)

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Completed 18 July 2020

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