Fillable Form INV 100 FOI PRIVACY ACT RECORD REQUEST FORM 2017

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Form INV 100 FOI PRIVACY ACT RECORD REQUEST FORM 2017

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FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM
Form Approved
OMB No. 3206-0259
U.S. Office of Personnel Management
National Background Investigations Bureau
INV 100
November 2017
Instructions: Use of this form is optional. You may use any written format for a Freedom of Information (FOIA) or Privacy
Act (PA) Request as long as it contains a description of the information you are requesting and sufficient personally
identifying data when required. Failure to provide the required information may result in no action being taken on the
request. Submit completed forms via fax, mail, or e-mail as scanned attachments. If submitting via e-mail, you should
ensure that the security of your e-mail system is adequate for transmitting sensitive information before choosing to
transmit your request, which contains your personally identifiable information. Mail: OPM-National Background
Investigations Bureau; ATTN: FOI/PA office, 1137 Branchton Road, P.O. Box 618, Boyers, PA 16018. Fax: (724) 794-4590.
e-Mail: FOIPARequests@nbib.gov.
1. Type of Request - (This section must be completed)
PA/FOIA Requests:
I request my own records. (Requester must complete sections 2, 3, 4, 5, and 7.)
FOIA Request:
I am making a request for records about someone or something other than myself.
(Requester must complete sections 2, 3, 7, and 8.)
PA Amendment Request:
I wish to amend my own records. In accordance with 5 C.F.R.§ 297.301, the burden of proof rests with the record subject to
illustrate how his/her record is not accurate, timely, relevant, or complete. Requesters should attach additional material to this form.
(Requester must complete sections 2, 4, 5, and 7.)
2. Requester Information - (This section must be completed)
Full Name:
Street Address:
City:
State:
Zip Code:
Country:
Preferred Delivery Method:
Secure e-Mail*
Hardcopy Mail
e-Mail Address:
Optional:
Telephone Number:
*A secure e-mail ensures that the information being sent to you is encrypted and therefore cannot be intercepted and read. Many widely
used e-mail providers accept this type of file. If your e-mail provider prohibits secure e-mails you will be notified to register with the OPM
server. This registration process will authenticate your identity and will allow the e-mail to be delivered directly to you.
3. Records Requested (Select One)
Page 1 of 3
Standard Form Only (SF86, 85P, or 85)
Most Recent Investigation, including Standard Form
All Investigations and Standard Forms
Other (Specify in the box below) - Attach a separate page if you need more space
than provided below.
Clear Form
4. Requester's Identifying Information -
(Complete this section only if you are making a request for records about yourself.)
Social Security Number:
Date of Birth: (MM/DD/YYYY)
City of Birth:
Form Approved
OMB No. 3206-0259
U.S. Office of Personnel Management
National Background Investigations Bureau
INV 100
November 2017
Page 2 of 3
State of Birth:
Country of Birth:
5. Identity Source Documents - (Copies of two identity source documents must be submitted along with this form).
Examples of acceptable identity source documents are provided on the OPM-National Background Investigations Bureau FOIA & Privacy
Act web page: https://nbib.opm.gov/foia-privacy-acts/requesting-and-amending-my-records/#AcceptIDSources
Copies of two identity source documents are attached.
6. Optional: Authorization to Release Information to a Third Party.
By completing this section, you aut
horize i
nformation relating to you to be released
to another
person,
such as a
fami
ly
member
or
legal
counsel.
Pl
ease note, i
f
you choose to have
your
records
sent
to a
third party,
you wi
ll not be
furnished
a
dupli
cate copy. Pursuant
to
5 U.S.C.
§ 552a(b), I authorize the United States Office of Personnel Management's, National Background Investigations Bureau to release my records
(defined
ab ove) to:
Full Name:
Mailing Address:
7. Verification of Requester's Identity -
(Complete this section only if you are making a request for records about yourself.)
I declare under the penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and I am the person named
in Section 2. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more than
$10,000, or by imprisonment for not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is punishable
under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.
Handwritten Signature:
Date:
8. Complete this section only if you are requesting records about someone or something other than yourself.
In the box below, you may wish to provide information about yourself and the purpose of your request to help us determine your fee category.
While FOIA does not require a requester to state the purpose of a request, fees may be reduced based on the nature of the requester or purpose
of the request. Fees for searching, copying, and processing records in this category may be levied in accordance with OPM's regulations at 5
C.F.R. § 294.109. If you are asking for a waiver or reduction of fees, you can also use this box to provide an explanation. Attach a separate page if
you need more space than provided below.
I agree to pay all applicable fees.
I agree to pay up to a specific amount for fees.
Specify the Amount
I request a waiver or reduction of fees because I am (check all options below that apply):
Affiliated with an education or noncommercial scientific institution and this request is not for commercial use.
A representative of the news media and this request is part of a news dissemination function and not for commercial use.
Requesting the information in order to contribute significantly to the public understanding of the operations or activities
of the government and I do not primarily have a commercial interest in the information.
FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM
Privacy Routine Use and Disclosure Information
Privacy Act Statement. Information provided by a requester will be used to locate and provide the requester responsive records
pursuant to the Freedom of Information Act (5 U.S.C. § 552), and/or the Privacy Act of 1974 (5 U.S.C. § 552a). Authority to
collect this information is contained in 5 U.S.C. § 552, 5 U.S.C. § 552a, 5 C.F.R. § 297.201(b). The purpose of the collection is to
enable the United States Office of Personnel Management (OPM), National Background Investigations Bureau to locate
applicable records and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Failure
to provide the required information may result in no action being taken on the request.
Routine Uses. The information collected on this form will primarily be used to comply with requests for information under
5 U.S.C. § 552 and 5 U.S.C. § 552a. The information requested may be used by and disclosed to OPM NBIB personnel,
contractors, and/or shared externally with other government agency personnel as a routine use when necessary and relevant
to assist in activities related to the processing of your Freedom of Information Act and/or Privacy Act request. Additionally,
OPM NBIB may use the information as necessary and authorized by the routine uses in the system of records notice associated
with this form: OPM Central 8, Privacy Act/Freedom of Information Act (PA/FOIA) Case Records. A complete list of the routine
uses and the full text of OPM Central 8 can be found at: https://www.opm.gov/information-management/privacy-policy/sorn/
opm-sorn-central-8-privacy-actfreedom-of-information-actpafoia-case-records.pdf.
Information Regarding Disclosure of your Social Security Number (SSN) under Public Law 93-579, Section 7 (b).
Solicitation of SSNs by OPM is authorized under the provisions of Executive Order 9397, dated November 22, 1943. Providing
your social security number is voluntary. You are asked to provide your social security number only to facilitate the
identification of records relating to you. Without your social security number, OPM may be unable to locate records pertaining
to you. The use of SSNs is necessary because of the large number of Federal employees, contractors, civilians and military
personnel who have identical names and/or birth date and whose identities can only be distinguished by their SSNs.
Public Burden Statement. Public burden reporting for this collection of information is estimated to vary from 5 to 15 minutes
with an average of 5 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
accuracy of this burden estimation and any suggestions for reducing the burden to: U.S. Office of Personnel Management,
National Background Investigations Bureau, Attn: OBM Number (3206-0259), 1900 E. Street NW, Washington, DC 20415-7900.
Form Approved
OMB No. 3206-0259
U.S. Office of Personnel Management
National Background Investigations Bureau
INV 100
November 2017
Page 3 of 3
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Form INV 100 FOI PRIVACY ACT RECORD REQUEST FORM 2017

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Completed 11 February 2020

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