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Sf85p (U.S. Office of Personnel Management)

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Questionnaire for Public Trust Positions
Standard Form 85P
Revised September 1995
OMB No. 3206-0191
Form approved:
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 7 and the release on
Page 8. If you have any questions, call the office that gave you the form.
Purpose of this Form
The U.S. Government conducts background investigations and
reinvestigations to establish that applicants or incumbents either
employed by the Government or working for the Government under
contract, are suitable for the job and/or eligible for a public trust or
sensitive position. Information from this form is used primarily as the
basis for this investigation. Complete this form only after a conditional
offer of employment has been made.
These include documentation of any legal name change, Social Security
card, and/or birth certificate.
You may also be asked to bring documents about information you
provided on the form or other matters requiring specific attention.
These matters include alien registration, delinquent loans or taxes,
bankruptcy, judgments, liens, or other financial obligations, agreements
involving child custody or support, alimony or property settlements,
arrests, convictions, probation, and/or parole.
Giving us the information we ask for is voluntary. However, we may
not be able to complete your investigation, or complete it in a timely
manner, if you don’t give us each item of information we request. This
may affect your placement or employment prospects.
Instructions for Completing this Form
1. Follow the instructions given to you by the person who gave you the
form and any other clarifying instructions furnished by that person to
assist you in completion of the form. Find out how many copies of the
form you are to turn in. You must sign and date, in black ink, the
original and each copy you submit.
Authority to Request this Information
The U.S. Government is authorized to ask for this information under
Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5,
U.S. Code; and parts 5, 731, 732, and 736 of Title 5, Code of Federal
Regulations.
2. Type or legibly print your answers in black ink (if your form is not
legible, it will not be accepted). You may also be asked to submit your
form in an approved electronic format.
Your Social Security number is needed to keep records accurate,
because other people may have the same name and birth date. Executive
Order 9397 also asks Federal agencies to use this number to help
identify individuals in agency records.
3. All questions on this form must be answered. If no response is
necessary or applicable, indicate this on the form (for example, enter
"None" or "N/A"). If you find that you cannot report an exact date,
approximate or estimate the date to the best of your ability and indicate
this by marking "APPROX." or "EST."
The Investigative Process
Background investigations are conducted using your responses on this
form and on your Declaration for Federal Employment (OF 306) to
develop information to show whether you are reliable, trustworthy, of
good conduct and character, and loyal to the United States. The
information that you provide on this form is confirmed during the
investigation. Your current employer must be contacted as part of the
investigation, even if you have previously indicated on applications or
other forms that you do not want this.
4. 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 the form consistent with your intent.
5. You must use the State codes (abbreviations) listed on the back of
this page when you fill out this form. Do not abbreviate the names of
cities or foreign countries.
In addition to the questions on this form, inquiry also is made about a
person’s adherence to security requirements, honesty and integrity,
vulnerability
to exploitation or coercion, falsification, mis-
representation, and any other behavior, activities, or associations that
tend to show the person is not reliable, trustworthy, or loyal.
6. The 5-digit postal ZIP codes are needed to speed the processing of
your investigation. The office that provided the form will assist you in
completing the ZIP codes.
7. All telephone numbers must include area codes.
8. All dates provided on this form must be in Month/Day/Year or
Month/Year format. Use numbers (1-12) to indicate months. For
example, June 10, 1978, should be shown as 6/10/78.
Your Personal Interview
Some investigations will include an interview with you as a normal part
of the investigative process. This provides you the opportunity to
update, clarify, and explain information on your form more completely,
which often helps to complete your investigation faster. It is important
that the interview be conducted as soon as possible 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.
9. Whenever "City (Country)" is shown in an address block, also
provide in that block the name of the country when the address is
outside the United States.
10. If you need additional space to list your residences or
employments/self-employments/unemployments
or education, you
should use a continuation sheet, SF 86A. If additional space is needed
to answer other items, use a blank piece of paper. Each blank piece of
paper you use must contain your name and Social Security Number
at the top of the page.
You will be asked to bring identification with your picture on it, such as
a valid State driver’s license, to the interview. There are other
documents you may be asked to bring to verify your identity as well.
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
NSN 7540-01-317-7372
85-1602
Your prospects of placement are better if you answer all questions
truthfully and completely. You will have adequate opportunity to
explain any information you give us on the form and to make your
comments part of the record.
Final Determination on Your Eligibility
Final determination on your eligibility for a public trust or sensitive
position and your being granted a security clearance is the responsibility
of the Office of Personnel Management or the Federal agency that
requested your investigation. You may be provided the opportunity
personally to explain, refute, or clarify any information before a final
decision is made.
Disclosure of Information
The information you give us is for the purpose of investigating you for a
position; we will protect it from unauthorized disclosure. The
collection, maintenance, and disclosure of background investigative
information is governed by the Privacy Act. The agency which
requested the investigation and the agency which conducted the
investigation have published notices in the Federal Register describing
the system of records in which your records will be maintained. You
may obtain copies of the relevant notices from the person who gave you
this form. The information on this form, and information we collect
during an investigation may be disclosed without your consent as
permitted by the Privacy Act (5 USC 552a(b)) and as follows:
Penalties for Inaccurate or False Statements
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 of up to $10,000, and/or 5 years imprisonment, or both. 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. Because the position for which
you are being considered is one of public trust or is sensitive, your
trustworthiness is a very important consideration in deciding your
suitability for placement or retention in the position.
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 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 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 21, 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 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.
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.
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.
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.
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.
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 USC 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review of
private relief legislation.
STATE CODES (ABBREVIATIONS)
Alabama
AL
Alaska
AK
Arizona
AZ
Arkansas
AR
California
CA
Colorado
CO
Connecticut
CT
Delaware
DE
Florida
FL
Georgia
GA
American Samoa
AS
Trust Territory
TT
Hawaii
HI
Idaho
ID
Illinois
IL
Indiana
IN
Iowa
IA
Kansas
KS
Kentucky
KY
Louisiana
LA
Maine
ME
Maryland
MD
District of Columbia
DC
Virgin Islands
VI
Massachusetts
MA
Michigan
MI
Minnesota
MN
Mississippi
MS
Missouri
MO
Montana
MT
Nebraska
NE
Nevada
NV
New Hampshire
NH
New Jersey
NJ
Guam
GU
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
Northern Marianas
CM
South Dakota
SD
Tennessee
TN
Texas
TX
Utah
UT
Vermont
VT
Virginia
VA
Washington
WA
West Virginia
WV
Wisconsin
WI
Wyoming
WY
Puerto Rico
PR
PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information is estimated to average 60 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 Reports
and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send
your completed form to this address.
Standard Form 85P (EG) Form approved:
Revised September 1995
QUESTIONNAIRE FOR
PUBLIC TRUST POSITIONS
OMB No. 3206-0191
U.S. Office of Personnel Management
NSN 7540-01-317-7372
5 CFR Parts 731, 732, and 736
85-1602
OPM
USE
ONLY
Codes Case Number
Agency Use Only
(Complete items A through P using instructions provided by USOPM)
A
Type of
Investigation
B
Extra
Coverage
C
Sensitivity/
Risk Level
D
Compu/
ADP
E
Nature of
Action Code
F
Date of
Action
Month Day Year
G
Geographic
Location
H
Position
Code
I
Position
Title
J
SON
K
Location
of Official
Personnel
Folder
None
NPRC
At SON
Other Address ZIP Code
L
SOI
M
Location
of Security
Folder
None
At SOI
NPI
Other Address ZIP Code
N
OPAC-ALC
Number
O
Accounting Data and/or
Agency Case Number
P
Requesting
Name and Title
Official
Signature Telephone Number
( )
Date
Persons completing this form should begin with the questions below.
1 FULL
NAME
If you have only initials in your name, use them and state (IO).
If you have no middle name, enter "NMN".
- If you are a "Jr.," "Sr.," "II," etc., enter this in the
box after your middle name.
Last Name First Name Middle Name Jr., II, etc.
2
DATE OF
BIRTH
Month Day Year
3
PLACE OF BIRTH - Use the two letter code for the State.
City County State Country
(if not in the United States)
4
SOCIAL SECURITY NUMBER
5
OTHER NAMES USED
Name
#1
Month/Year
To
Month/Year
Name
#2
Month/Year
To
Month/Year
Name
#3
Month/Year
To
Month/Year
Name
#4
Month/Year
To
Month/Year
6
OTHER
IDENTIFYING
INFORMATION
Height
(feet and inches)
Weight
(pounds)
Hair Color Eye Color
Sex
(Mark one box)
Female Male
7
TELEPHONE
NUMBERS
Work
(include Area Code and extension)
Day
Night
( )
Home
(include Area Code)
Day
Night
)(
8
CITIZENSHIP
a
Mark the box at the right that
reflects your current citizenship
status, and follow its instructions.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession.
Answer
items b and d.
I am a U.S. citizen, but I was NOT born in the U.S.
Answer items b, c and d.
I am not a U.S. citizen.
Answer items b and e.
b
Your Mother’s Maiden Name
c
UNITED STATES CITIZENSHIP If you are a U.S. Citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.
Naturalization Certificate
(Where were you naturalized?)
Court City State Certificate Number Month/Day/Year Issued
Citizenship Certificate
(Where was the certificate issued?)
City State Certificate Number Month/Day/Year Issued
State Department Form 240 - Report of Birth Abroad of a Citizen of the United States
Give the date the form was
prepared and give an explanation
if needed.
Month/Day/Year Explanation
U.S. Passport
This may be either a current or previous U.S. Passport
Passport Number Month/Day/Year Issued
d
DUAL CITIZENSHIP If you are
(or were)
a dual citizen of the United States and another country,
provide the name of that country in the space to the right.
Country
e
ALIEN If you are an alien, provide the following information:
Place You
Entered the
United States:
City State Date You Entered U.S.
Month Day Year
Alien Registration Number Country(ies) of Citizenship
Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995.
Page 1
Designed using Perform Pro, WHS/DIOR, Sep 95
9
WHERE YOU HAVE LIVED
List the places where you have lived, beginning with the most recent (#1) and working back 7 years. All periods must be accounted for in your list. Be sure to indicate the
actual physical location of your residence: do not use a post office box as an address, do not list a permanent address when you were actually living at a school address,
etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or home port. You may omit
temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas.
For any address in the last 5 years, list a person who knew you at that address, and who preferably still lives in that area (do not list people for residences completely
outside this 5-year period, and do not list your spouse, former spouses, or other relatives). Also for addresses in the last 5 years, if the address is "General Delivery," a
Rural or Star Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet.
#1
Month/Year
To
Month/Year
Present
Street Address Apt. # City (Country) State ZIP Code
Name of Person Who Knows You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
#2
Month/Year
To
Month/Year Street Address Apt. # City (Country) State ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
#3
Month/Year
To
Month/Year Street Address Apt. # City (Country) State ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
#4
Month/Year
To
Month/Year Street Address Apt. # City (Country) State ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
#5
Month/Year
To
Month/Year Street Address Apt. # City (Country) State ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
10
WHERE YOU WENT TO SCHOOL
List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 7 years. List all College or University degrees
and the dates they were received. If all of your education occurred more than 7 years ago, list your most recent education beyond high school, no matter when that
education occurred.
Use one of the following codes in the "Code" block:
1 - High School 2 - College/University/Military College 3 - Vocational/Technical/Trade School
For schools you attended in the past 3 years, list a person who knew you at school (an instructor, student, etc.). Do not list people for education
completely outside this 3-year period.
For correspondence schools and extension classes, provide the address where the records are maintained.
#1
Month/Year
To
Month/Year Code Name of School Degree/Diploma/Other Month/Year Awarded
Street Address and City (Country) of School State ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
#2
Month/Year
To
Month/Year Code Name of School Degree/Diploma/Other Month/Year Awarded
Street Address and City (Country) of School
State ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
(
)
#3
Month/Year
To
Month/Year Code
Name of School Degree/Diploma/Other Month/Year Awarded
Street Address and City (Country) of School State
ZIP Code
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Enter your Social Security Number before going to the next page
Page 2
11 YOUR EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 7 years. You should list all full-time work, part-time work, military service,
temporary military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 7-year period must be accounted for
without breaks, but you need not list employments before your 16th birthday.
Code. Use one of the codes listed below to identify the type of employment:
1 - Active military duty stations
2 - National Guard/Reserve
3 - U.S.P.H.S. Commissioned Corps
4 - Other Federal employment
5 - State Government (Non-Federal
employment)
6 - Self-employment (Include business
and/or name of person who can verify)
7 - Unemployment (Include name of
person who can verify)
8 - Federal Contractor (List Contractor,
not Federal agency)
9 - Other
Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this block. If
military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in
your military duty locations or home ports.
Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most recent
period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you
worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first,
and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.
#1
Month/Year
To
Month/Year
Present
Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #1)
Month/Year
To
Month/Year
Position Title
Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Month/Year
To
Month/Year Position Title Supervisor
#2
Month/Year
To
Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #2)
Month/Year
To
Month/Year
Position Title
Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Month/Year
To
Month/Year Position Title Supervisor
#3
Month/Year
To
Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #3)
Month/Year
To
Month/Year
Position Title
Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Enter your Social Security Number before going to the next page
Page 3
YOUR EMPLOYMENT ACTIVITIES
(CONTINUED)
#4
Month/Year
To
Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #4)
Month/Year
To
Month/Year
Position Title
Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Month/Year
To
Month/Year Position Title Supervisor
#5
Month/Year
To
Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #5)
Month/Year
To
Month/Year
Position Title
Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Month/Year
To
Month/Year Position Title Supervisor
#6
Month/Year
To
Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #6)
Month/Year
To
Month/Year
Position Title
Supervisor
Month/Year
To
Month/Year Position Title Supervisor
Month/Year
To
Month/Year Position Title Supervisor
12
YOUR EMPLOYMENT RECORD
Has any of the following happened to you in the last 7 years? If "Yes," begin with the most recent occurrence and go backward, providing date
fired, quit, or left, and other information requested.
Yes
No
Use the following codes and explain the reason your employment was ended:
1 - Fired from a job
2 - Quit a job after being told
you’d be fired
3 - Left a job by mutual agreement following allegations of misconduct
4 - Left a job by mutual agreement following allegations of
unsatisfactory performance
5 - Left a job for other reasons
under unfavorable circumstances
Month/Year Code
Specify Reason Employer’s Name and Address
(Include city/Country if outside U.S.)
State ZIP Code
Enter your Social Security Number before going to the next page
Page 4
13
PEOPLE WHO KNOW YOU WELL
List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose combined
association with you covers as well as possible the last 7 years. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is listed
elsewhere on this form.
Name
#1
Dates Known
Month/Year
To
Month/Year
Telephone Number
Day
Night
( )
Home or Work Address City (Country) State ZIP Code
Name
#2
Dates Known
Month/Year
To
Month/Year
Telephone Number
Day
Night
( )
Home or Work Address
City (Country) State ZIP Code
Name
#3
Dates Known
Month/Year
To
Month/Year
Telephone Number
Day
Night
( )
Home or Work Address City (Country) State ZIP Code
14
YOUR MARITAL STATUS
Mark one of the following boxes to show your current marital status:
1 - Never married
(go to question 15)
2 - Married
3 - Separated
4 - Legally Separated
5 - Divorced
6 - Widowed
Current Spouse Complete the following about your current spouse.
Full Name Date of Birth
(Mo./Day/Yr.)
Place of Birth
(Include country if outside the U.S.)
Social Security Number
Other Names Used
(Specify maiden name, names by other marriages, etc., and show dates used for each name)
Country of Citizenship Date Married
(Mo./Day/Yr.)
Place Married
(Include country if outside the U.S.)
State
If Separated, Date of Separation
(Mo./Day/Yr.)
If Legally Separated, Where is the Record Located? City
(Country)
State
Address of Current Spouse
(Street, city, and country if outside the U.S.)
State ZIP Code
15
YOUR RELATIVES
Give the full name, correct code, and other requested information for each of your relatives, living or dead, specified below.
1 - Mother
(first)
2 - Father
(second)
3 - Stepmother
4 - Stepfather
5 - Foster Parent
6 - Child
(adopted also)
7 - Stepchild
Full Name
(If deceased, check box on the
left before entering name)
Code
Date of Birth
Month/Day/Year
Country of Birth
Country(ies) of
Citizenship
Current Street Address and City
(country)
of
Living Relatives
State
1
2
Enter your Social Security Number before going to the next page
Page 5
16
YOUR MILITARY HISTORY
a
Have you served in the United States military?
Yes No
b
Have you served in the United States Merchant Marine?
List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service (#1) and work
backward. If you had a break in service, each separate period should be listed.
Code. Use one of the codes listed below to identify your branch of service:
1 - Air Force 2 - Army 3 - Navy 4 - Marine Corps 5 - Coast Guard 6 - Merchant Marine 7 - National Guard
O/E. Mark "O" block for Officer or "E" block for Enlisted.
Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use
an "X": use the two-letter code for the state to mark the block.
Country. If your service was with other than the U.S. Armed Forces, identify the country for which you served.
Month/Year Month/Year
Code Service/Certificate No.
O E
Status
Active
Reserve
Active Inactive
Reserve
National
Guard
(State)
Country
To
To
17
YOUR SELECTIVE SERVICE RECORD
a
Are you a male born after December 31, 1959? If "No," go to 18. If "Yes," go to b.
Yes No
b
Have you registered with the Selective Service System? If "Yes," provide your registration number. If "No," show the reason for your legal
exemption below.
Registration Number Legal Exemption Explanation
18
YOUR INVESTIGATIONS RECORD
a
Has the United States Government ever investigated your background and/or granted you a security clearance? If "Yes," use the codes that
follow to provide the requested information below. If "Yes," but you can’t recall the investigating agency and/or the security clearance
received, enter "Other" agency code or clearance code, as appropriate, and "Don’t know" or "Don’t recall" under the "Other Agency"
heading, below. If your response is "No," or you don’t know or can’t recall if you were investigated and cleared, check the "No" box.
Yes No
Codes for Investigating Agency
1 - Defense Department
2 - State Department
3 - Office of Personnel Management
4 - FBI
5 - Treasury Department
6 - Other
(Specify)
Codes for Security Clearance Received
0 - Not Required
1 - Confidential
2 - Secret
3 - Top Secret
4 - Sensitive Compartmented Information
5 - Q
6 - L
7 - Other
Month/Year
Agency
Code
Other Agency
Clearance
Code
Month/Year
Agency
Code
Other Agency
Clearance
Code
b
To your knowledge, have you ever had a clearance or access authorization denied, suspended, or revoked, or have you ever been debarred
from government employment? If "Yes," give date of action and agency. Note: An administrative downgrade or termination of a security
clearance is not a revocation.
Yes No
Month/Year
Department or Agency Taking Action
Month/Year
Department or Agency Taking Action
19
FOREIGN COUNTRIES YOU HAVE VISITED
List foreign countries you have visited, except on travel under official Government orders, beginning with the most current (#1) and working back 7 years. (Travel as a
dependent or contractor must be listed.)
Use one of these codes to indicate the purpose of your visit: 1 - Business 2 - Pleasure 3 - Education 4 - Other
Include short trips to Canada or Mexico. If you have lived near a border and have made short (one day or less) trips to the neighboring country, you do
not need to list each trip. Instead, provide the time period, the code, the country, and a note ("Many Short Trips").
Do not repeat travel covered in items 9, 10, or 11.
Month/Year Month/Year Code
Country
#1
To
To#2
To#3
To#4
Month/Year Month/Year Code
Country
#5
To
To#6
To#7
To#8
Enter your Social Security Number before going to the next page
Page 6
20
YOUR POLICE RECORD
(Do not include anything that happened before your 16th birthday.)
In the last 7 years, have you been arrested for, charged with, or convicted of any offense(s)? (Leave out traffic fines of less than $150.)
Yes
No
If you answered "Yes," explain your answer(s) in the space provided.
Month/Year Offense Action Taken Law Enforcement Authority or Court
(City and county/country if outside the U.S.)
State ZIP Code
21
ILLEGAL DRUGS
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your
failure to do so could be grounds for an adverse employment decision or action against you, but neither your truthful responses nor information
derived from your responses will be used as evidence against you in any subsequent criminal proceeding.
a
In the last year, have you illegally used any controlled substance, for example, marijuana, cocaine, crack cocaine, hashish, narcotics (opium,
morphine, codeine, heroin, etc.), amphetamines, depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), or
prescription drugs?
Yes No
b
In the last 7 years, have you been involved in the illegal purchase, manufacture, trafficking, production, transfer, shipping, receiving, or sale of any
narcotic, depressant, stimulant, hallucinogen, or cannabis, for your own intended profit or that of another?
If you answered "Yes" to "a" above, provide information relating to the types of substance(s), the nature of the activity, and any other details relating
to your involvement with illegal drugs. Include any treatment or counseling received.
Month/Year Month/Year
Controlled Substance/Prescription Drug Used Number of Times Used
To
To
To
22
YOUR FINANCIAL RECORD
a
In the last 7 years, have you, or a company over which you exercised some control, filed for bankruptcy, been declared bankrupt, been subject to a
tax lien, or had legal judgment rendered against you for a debt? If you answered "Yes," provide date of initial action and other information requested
below.
Yes
No
Month/Year Type of Action Name Action Occurred Under Name/Address of Court or Agency Handling Case
State ZIP Code
b Are you now over 180 days delinquent on any loan or financial obligation? Include loans or obligations funded or guaranteed by the Federal
Government.
Yes
No
If you answered "Yes," provide the information requested below:
Month/Year
Type of Loan or Obligation
and Account #
Name/Address of Creditor or Obligee
State ZIP Code
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the
following certification and sign and date the release on Page 8.
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).
Signature
(Sign in ink)
Date
Enter your Social Security Number before going to the next page
Page 7
Standard Form 85P
Revised September 1995
OMB No. 3206-0191
Form approved:
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
NSN 7540-01-317-7372
85-1602
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my
background investigation, to obtain any information relating to my activities from individuals, schools, residential management
agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business
establishments, or other sources of information. This information may include, but is not limited to, my academic, residential,
achievement, performance, attendance, disciplinary, employment history, criminal history record information, and financial and
credit information. I authorize the Federal agency conducting my investigation to disclose the record of my background
investigation to the requesting agency for the purpose of making a determination of suitability or eligibility for a security clearance.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of
information, a separate specific release will be needed, and I may be contacted for such a release at a later date. Where a separate
release is requested for information relating to mental health treatment or counseling, the release will contain a list of the specific
questions, relevant to the job description, which the doctor or therapist will be asked.
I Further Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office of Personnel
Management, the Federal Bureau of Investigation, the Department of Defense, the Defense Investigative Service, and any other
authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for assignment to, or retention in a sensitive National Security position, in accordance with 5 U.S.C. 9101.
I understand that I may request a copy of such records as may be available to me under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the
investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous
agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by the Federal
Government only for the purposes provided in this Standard Form 85P, and that it may be redisclosed by the Government only as
authorized by law.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for
five (5) years from the date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Signature
(Sign in ink)
Full Name
(Type or Print Legibly)
Date Signed
Other Names Used Social Security Number
Current Address
(Street, City)
State ZIP Code Home Telephone Number
(Include Area Code)
( )
Page 8
Standard Form 85P
Revised September 1995
OMB No. 3206-0191
Form approved:
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
NSN 7540-01-317-7372
85-1602
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Carefully read this authorization to release information about you, then sign and date it in black ink.
Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) the three questions below concerning your mental health
consultations. Your signature will allow the practitioner(s) to answer only these questions.
I am seeking assignment to or retention in a position of public trust with the Federal Government as a(n)
(Investigator instructed to write in position title.)
As part of the investigative process, I hereby authorize the investigator, special agent, or duly accredited representative of the
authorized Federal agency conducting my background investigation, to obtain the following information relating to my mental health
consultations:
Does the person under investigation have a condition or treatment that could impair his/her judgment or reliability?
If so, please describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
I understand that the information released pursuant to this release is for use by the Federal Government only for purposes provided in
the Standard Form 85P and that it may be redisclosed by the Government only as authorized by law.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for 1
year from the date signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
Signature
(Sign in ink)
Full Name
(Type or Print Legibly)
Date Signed
Other Names Used Social Security Number
Current Address
(Street, City)
State ZIP Code Home Telephone Number
(Include Area Code)
( )
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