Fillable Sf86 Standard Form 86 - Questionnaire for National Security

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Sf86 Standard Form 86 - Questionnaire for National Security

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Depending upon the purpose of your investigation, the 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, United States
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 (CFR).
Your Social Security Number (SSN) is needed to identify records unique to
you. 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, as amended by EO 13478.
This form will be used by the United States (U.S.) Government in conducting
background investigations, reinvestigations, and continuous evaluations of
persons under consideration for, or retention of, national security positions as
defined in 5 CFR 732, and for individuals requiring eligibility for access to
classified information under Executive Order 12968. This form may also be
used by agencies in determining whether a subject performing work for, or on
behalf of, the Government under a contract should be deemed eligible for
logical or physical access when the nature of the work to be performed is
sensitive and could bring about an adverse effect on the national security.
This form may become a permanent document that may be used as the basis
for future investigations, eligibility determinations for access to classified
information, or to hold a sensitive position, suitability or fitness for Federal
employment, fitness for contract employment, or eligibility for physical and
logical access to federally controlled facilities or information systems. Your
responses to this form may be compared with your responses to previous
SF-86 questionnaires.
Providing this information is voluntary. If you do not provide each item of
requested information, however, we will not be able to complete your
investigation, which will adversely affect your eligibility for a national security
position, eligibility for access to classified information, or logical or physical
access. It is imperative that the information provided be true and accurate, to
the best of your knowledge. Any information that you provide is evaluated on
the basis of its currency, seriousness, relevance to the position and duties,
and consistency with all other information about you. Withholding,
misrepresenting, or falsifying information may affect your eligibility for access
to classified information, eligibility for a sensitive position, or your ability to
obtain or retain Federal or contract employment. In addition, withholding,
misrepresenting, or falsifying information may affect your eligibility for
physical and logical access to federally controlled facilities or information
systems. Withholding, misrepresenting, or falsifying information may also
negatively affect your employment prospects and job status, and the potential
consequences include, but are not limited to, removal, debarment from
Federal service, loss of eligibility for access to classified information, or
prosecution.
Authority to Request this Information
Follow instructions completely or your form will be unable to be processed. If
you have any questions, contact the office that provided you the form.
All questions on this form must be answered completely and truthfully in
order that the Government may make the determinations described below on
a complete record. Penalties for inaccurate or false statements are discussed
below. If you are a current civilian employee of the federal government:
failure to answer any questions completely and truthfully could result in an
adverse personnel action against you, including loss of employment; with
respect to Sections 23, 27, and 29, however, neither your truthful responses
nor information derived from those responses will be used as evidence
against you in a subsequent criminal proceeding.
The investigation conducted on the basis of information provided on this form
may be selected for studies and analyses in support of evaluating and
improving the effectiveness and efficiency of the investigative and
adjudicative methodologies. All study results released to the general public
will delete personal identifiers such as name, Social Security Number, and
date and place of birth.
Background investigations for national security positions are conducted to
gather information to determine whether you are reliable, trustworthy, of good
conduct and character, and loyal to the U.S. The information that you provide
on this form may be confirmed during the investigation. The investigation may
extend beyond the time covered by this form, when necessary to resolve
issues. Your current employer may be contacted as part of the investigation,
although you may have previously indicated on applications or other forms
that you do not want your current employer to be contacted. If you have a
security freeze on your consumer or credit report file, then we may not be
able to complete your investigation, which can adversely affect your eligibility
for a national security position. To avoid such delays, you should request that
the consumer reporting agencies lift the freeze in these instances.
The Investigative Process
In addition to the questions on this form, inquiry also is made about your
adherence to security requirements, your honesty and integrity, vulnerability
to exploitation or coercion, falsification, misrepresentation, and any other
behavior, activities, or associations that tend to demonstrate a person is not
reliable, trustworthy, or loyal. Federal agency records checks may be
conducted on your spouse or legally recognized civil union/domestic partner,
cohabitant(s), and immediate family members. After an eligibility
determination has been completed, you also may be subject to continuous
evaluation, which may include periodic reinvestigations, to determine whether
retention in your position is clearly consistent with the interests of national
security.
The information you provide on this form may be confirmed during the
investigation, and may be used for identification purposes throughout the
investigation process.
For the interview, you will be required to provide photo identification, such as
a valid state driver's license. You may be required to provide other documents
to verify your identity, as instructed by your investigator. These documents
may include certification of any legal name change, Social Security card,
passport, and/or your birth certificate. You may also be asked to provide
documents regarding information that you provide on this form, or about other
matters requiring specific attention. These matters include (a) alien
registration or naturalization documents; (b) delinquent loans or taxes,
bankruptcies, judgments, liens, or other financial obligations; (c) agreements
involving child custody or support, alimony, or property settlements; (d)
arrests, convictions, probation, and/or parole; or (e) other matters described
in court records.
Some investigations will include an interview with you as a routine part of the
investigative process. The investigator may ask you to explain your answers
to any question on this form. This provides you the opportunity to update,
clarify, and explain information on your form more completely, which often
assists in completing your investigation. It is imperative 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.
Your Personal Interview
Instructions for Completing this Form
2.
3.
1. Follow the instructions provided to you by the office that gave you this
form and any other clarifying instructions, provided by that office, to assist
you with completion of this form. You must sign and date, in ink, the
original and each copy you submit. You should retain a copy of the
completed form for your records.
All questions on this form must be answered. If no response is necessary
or applicable, indicate this on the form by checking the associated "Not
Applicable" box, unless otherwise noted.
Do not abbreviate the names of cities or foreign countries. Whenever
you are asked to supply a country name, you may select the country
name by using the country dropdown feature.
When entering a U.S. address or location, select the state or territory
from the "States" dropdown list that will be provided. For locations outside
of the U.S. and its territories, select the country in the "Country"
dropdown list and leave the "State" field blank.
4.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
Purpose of this Form
5.
7.
6.
The 5-digit postal Zip Codes are required to process your investigation
more rapidly. Refer to an automated system approved by the U.S. Postal
Service to assist you with Zip Codes.
For telephone numbers in the U.S., ensure that the area code is included.
All dates provided in this form must be in Month/Day/Year or Month/Year
format. Use numbers (01-12) to indicate months. For example, July 29,
1968, should be written as 07/29/1968. If you are unable to report an
exact date, approximate or estimate the date to the best of your ability,
and indicate "APPROX." or "EST" in the field.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
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
and/or up to five (5) years imprisonment. 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. Your prospects of placement
or security clearance are better if you answer all questions truthfully and
completely. You will have adequate opportunity to explain any information you
provide on this form and to make your comments part of the record.
Penalties for Inaccurate or False Statements
The information you provide is for the purpose of investigating you for a
national security position, and the information will be protected from
unauthorized disclosure. The collection, maintenance, and disclosure of
background investigative information are governed by the Privacy Act. The
agency that requested the investigation and the agency that conducted the
investigation have published notices in the Federal Register describing the
systems of records in which your records will be maintained. The information
you provide on this form, and information collected during an investigation,
may be disclosed without your consent by an agency maintaining the
information in a system of records as permitted by the Privacy Act [5 U.S.C.
552a(b)], and by routine uses, a list of which are published by the agency in
the Federal Register. The office that gave you this form will provide you a
copy of its routine uses.
You will not receive prior notice of such disclosures under a routine use.
In addition to those disclosures generally permitted under the Privacy Act, all
or a portion of the records or information you provide on this form or during
your investigation may be disclosed outside of OPM as a routine use as
outlined below.
Disclosure Information
Office of Personnel Management (OPM) Routine Uses
a. To designated officers and employees of agencies, offices, and other
establishments in the executive, legislative, and judicial branches of the
Federal Government or the Government of the District of Columbia having
a need to investigate, evaluate, or make a determination regarding loyalty
to the United States; qualifications, suitability, or fitness for Government
employment or military service; eligibility for logical or physical access to
federally-controlled facilities or information systems; eligibility for access to
Final determination on your eligibility for a national security position is the
responsibility of the Federal agency that requested your investigation and the
agency that conducted your investigation. You will be provided the opportunity
to explain, refute, or clarify any information before a final decision is made, if
an unfavorable decision is considered. The United States Government does
not discriminate on the basis of prohibited categories, including but not limited
to race, color, religion, sex (including pregnancy and gender identity), national
origin, disability, or sexual orientation when granting access to classified
information.
Final Determination on Your Eligibility
classified information or to hold a sensitive position; qualifications or
fitness to perform work for or on behalf of the Government under
contract, grant, or other agreement; or access to restricted areas.
b.
To an element of the U.S. Intelligence Community as identified in E.O.
12333, as amended, for use in intelligence activities for the purpose of
protecting United States national security interests.
c.
To any source from which information is requested in the course of an
investigation, 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.
d. To the appropriate Federal, state, local, tribal, foreign, or other public
authority responsible for investigating, prosecuting, enforcing, or
implementing a statute, rule, regulation, or order where OPM becomes
aware of an indication of a violation or potential violation of civil or
criminal law or regulation.
e.
To an agency, office, or other establishment in the executive, legislative,
or judicial branches of the Federal Government in response to its
request, in connection with its current employee’s, contractor
employee’s, or military member’s retention; loyalty; qualifications,
suitability, or fitness for employment; eligibility for logical or physical
access to federally-controlled facilities or information systems; eligibility
for access to classified information or to hold a sensitive position;
qualifications or fitness to perform work for or on behalf of the
Government under contract, grant, or other agreement; or access to
restricted areas.
f.
To provide information to a congressional office from the record of an
individual in response to an inquiry from the congressional office made at
the request of that individual. However, the investigative file, or parts
thereof, will only be released to a congressional office if OPM receives a
notarized authorization or signed statement under 28 U.S.C. 1746 from
the subject of the investigation.
g
.
To disclose information to contractors, grantees, or volunteers performing
or working on a contract, service, grant, cooperative agreement, or job
for the Federal Government.
h. For agencies that use adjudicative support services of another agency, at
the request of the original agency, the results will be furnished to the
agency providing the adjudicative support.
i.
To provide criminal history record information to the FBI, to help ensure
the accuracy and completeness of FBI and OPM records.
j. To appropri
ate agencies, entities, and persons when (1) OPM suspects
or has confirmed that there has been a breach of the system of records;
(2) OPM has determined that as a result of the suspected or confirmed
breach there is a risk of harm to individuals, the agency (including its
information systems, programs and operations), the Federal
Government, or national security; and (3) the disclosure made to such
agencies, entities, and persons is reasonably necessary to assist in
connection with OPM’s efforts to respond to the suspected or confirmed
breach or to prevent, minimize, or remedy such harm.
k.
To another Federal agency or Federal entity, when OPM determines that
information from this system of records is reasonably necessary to assist
the recipient agency or entity in (1) responding to a suspected or
confirmed breach or (2) preventing, minimizing, or remedying the risk of
harm to individuals, the agency (including its information systems,
programs and operations), the Federal Government, or national security,
resulting from a suspected or confirmed breach.
l.
To disclose information to another Federal agency, to a court, or a party
in litigation before a court or in an administrative proceeding being
conducted by a Federal agency, when the Government is a party to the
judicial or administrative proceeding. In those cases where the
Government is not a party to the proceeding, records may be disclosed if
a subpoena has been signed by a judge.
m.
To disclose information to the National Archives and Records
Administration for use in records management inspections.
OPM has published the following Privacy Act routine uses for its system of
records for background investigations:
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
u. To appropriately cleared individuals in Federal agencies, to determine
whether information obtained in the course of processing the background
investigation is or should be classified.
v.
To the Office of the Director of National Intelligence for inclusion in its
Scattered Castles system in order to facilitate reciprocity of background
investigations and security clearances within the intelligence community
or assist agencies in obtaining information required by the Federal
Investigative Standards.
w.
To the Director of National Intelligence, or assignee, such information as
may be requested and relevant to implement the responsibilities of the
Security Executive Agent for personnel security, and pertinent personnel
security research and oversight, consistent with law or executive order.
x.
To Executive Branch Agency insider threat, counterintelligence, and
counterterrorism officials to fulfill their responsibilities under applicable
Federal law and policy, including but not limited to E.O. 12333, 13587
and the National Insider Threat Policy and Minimum Standards.
y.
To the appropriate Federal, State, local, tribal, foreign, or other public
authority in the event of a natural or manmade disaster. The record will
be used to provide leads to assist in locating missing subjects or assist in
determining the health and safety of the subject. The record will also be
used to assist in identifying victims and locating any surviving next of kin.
z. To Federal, State, and local government agencies, if necessary, to obtain
information from them which will assist OPM in its responsibilities as the
authorized Investigation Service Provider in conducting studies and
analyses in support of evaluating and improving the effectiveness and
efficiency of the background investigation methodologies.
aa. To an agency, office, or other establishment in the executive, legislative,
or judicial branches of the Federal Government in response to its
request, in connection with the classifying of jobs, the letting of a
contract, or the issuance of a license, grant, or other benefit by the
requesting agency, to the extent that the information is relevant and
necessary to the requesting agency’s decision on the matter.
Public Burden Information
Public burden reporting for this collection of information is estimated to
average 150 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
U.S. Office of Personnel Management, Federal Investigative Services, Attn:
OMB Number 3206-0005, 1900 E Street, N.W., Washington, DC 20415.
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.
n. To disclose information to the Department of Justice, or in a proceeding
before a court, adjudicative body, or other administrative body before
which OPM is authorized to appear, when:
(1) OPM, or any component thereof; or
(2) Any employee of OPM in his or her official capacity; or
(3) Any employee of OPM in his or her individual capacity where
the Department of Justice or OPM has agreed to represent the
employee; or
(4) The United States, when OPM determines that litigation is
likely to affect OPM or any of its components; is a party to
litigation or has an interest in such litigation, and the use of
such records by the Department of Justice or OPM is deemed
by OPM to be relevant and necessary to the litigation,
provided, however, that the disclosure is compatible with the
purpose for which records were collected.
o.
For the Merit Systems Protection Board--To disclose information to
officials of the Merit Systems Protection Board or the Office of the
Special Counsel, when requested in connection with appeals, special
studies of the civil service and other merit systems, review of OPM rules
and regulations, investigations of alleged or possible prohibited
personnel practices, and such other functions, e.g., as promulgated in 5
U.S.C. 1205 and 1206, or as may be authorized by law.
p. To disclose information to an agency Equal Employment Opportunity
(EEO) office or to the Equal Employment Opportunity Commission when
requested in connection with investigations into alleged or possible
discrimination practices in the Federal sector, or in the processing of a
Federal-sector EEO complaint.
q.
To disclose information to the Federal Labor Relations Authority or its
General Counsel when requested in connection with investigations of
allegations of unfair labor practices or matters before the Federal Service
Impasses Panel.
r.
To another Federal agency’s Office of Inspector General when OPM
becomes aware of an indication of misconduct or fraud during the
applicant’s submission of the standard forms.
s.
To another Federal agency’s Office of Inspector General in connection
with its inspection or audit activity of the investigative or adjudicative
processes and procedures of its agency as authorized by the Inspector
General Act of 1978, as amended, exclusive of requests for civil or
criminal law enforcement activities.
t.
To a Federal agency or state unemployment compensation office upon
its request in order to adjudicate a claim for unemployment
compensation benefits when the claim for benefits is made as the result
of a qualifications, suitability, fitness, security, identity credential, or
access determination.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
LOCATION CODES
South Dakota SD
Tennessee TN
Texas TX
Utah UT
Vermont VT
Virginia VA
Washington WA
West Virginia WV
Wisconsin WI
Wyoming WY
Wake Island WQ
APO/FPO America AA
APO/FPO Europe AE
APO/FPO Pacific AP
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
Palmyra Atoll LQ
Puerto Rico PR
Virgin Islands, United VI
States
Massachusetts MA
Michigan MI
Minnesota MN
Mississippi MS
Missouri MO
Montana MT
Nebraska NE
Nevada NV
New Hampshire NH
New Jersey NJ
Midway Islands MQ
Navassa Island BQ
Northern Mariana Islands
MP
Palau PW
Hawaii HI
Idaho ID
Illinois IL
Indiana IN
Iowa IA
Kansas KS
Kentucky KY
Louisiana LA
Maine ME
Maryland MD
Johnson Atoll JQ
Kingman Reef KQ
Marshall Islands MH
Micronesia, Federated FM
States
Alabama AL
Alaska AK
Arizona AZ
Arkansas AR
California CA
Colorado CO
Connecticut CT
Delaware DE
District of Columbia DC
Florida FL
Georgia GA
American Samoa AS
Baker Island FQ
Guam GU
Howland Island HQ
Jarvis Island DQ
V Applicant affiliation
None
J SON
(Submitting Office Number)
Initial
Reinvestigation
S Investigative requirement
Investigating agency user only
Codes: (FIPC CODES)
Case Number:
P Obligating document number Q BETC
R Accounting data and/or Agency case number
T Requesting Official - Name
Title Signature
Title
Telephone number
(Include Ext.)
FED CIV
CON
Other
Other address/Web address of e-OPF
Zip Code
A Type of investigation
C Sensitivity level D Access/Eligibility E Nature of action code
G Geographic location
H Position code I Position title
K Location of Official Personnel Folder
U Secondary Requesting Official - Name
B Extra coverage/Advanced results
NPRC
At SON
e-OPF
Other
L SOI (Security Office Identifier) M Location of Security Folder
None
NPI
At SOI
Other
Other address
Email address
Email address Telephone number (Include Ext.) Date (Month/Day/Year)
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED
IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE
DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
Zip Code
MIL
N IPAC
O TAS
AGENCY USE BLOCK "AUB"
W Deployment/PCS (if imminent)
Point of contact at location Address/Unit/Duty location (Include City or Post Name)
Commercial and Government Entity (CAGE) Code Contract Number
F Date of action (Month/Day/Year)
Agency Special Instructions for the Investigative Service Provider.
Reason(s) for temporary duty assignment or PCSFrom (Month/Day/Year)
Telephone number (Include Ext.)
Est.
Permanent Relocation
Est. To (Month/Day/Year)
Provide your other name(s) used and the period of time you used it/them [for example: your maiden name, name(s) by a former marriage, former name(s),
alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No
Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#1
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Section 5 - Other Names Used
YES NO (If NO, proceed to Section 6)
Have you used any other names?
Complete the following if you have responded 'Yes' to having used other names.
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#2
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#3
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#4
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Page 2
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle
Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Enter your Social Security Number before going to the next page
Section 3 - Place of Birth
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject
to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), denial or revocation of a
security clearance, and/or removal and debarment from Federal Service.
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING
THE PRECEDING INSTRUCTIONS.
YES NO
Provide your place of birth.
Last name
First name
Middle name
City
County
Country (Required)
State
Not applicable
Provide your U.S. Social Security Number.
Section 4 - Social Security Number
Male
Female
Sex
Section 6 - Your Identifying Information
Weight
(in pounds) Hair color Eye color
Provide your identifying information.
Suffix
(feet) (inches)
Height
Section 2 - Date of Birth
Section 1 - Full Name
Provide your date of
birth. (Month/Day/Year)
Est.
Page 3
Section 8 - U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
YES NO (If NO, proceed to Section 9)
Provide the following information for the most recent U.S. passport you currently possess.
Passport number
The following link will provide U.S. State Department
passport help. http://travel.state.gov/passport
Issue date Expiration date
Est.
Provide the name in which passport was first issued.
Middle name
Last name
First name
Suffix
Section 9 - Citizenship
Select the box that reflects your current citizenship status.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
(Proceed to Section 10)
I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.
(Complete 9.1)
I am a naturalized U.S. citizen. (Complete 9.2)
I am a derived U.S. citizen. (Complete 9.3)
I am not a U.S. citizen. (Complete 9.4)
Provide document number for U.S. citizen born abroad.
Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)
Country
State
City
Provide the name in which document was issued.
Middle name
Last name
First name
Suffix
Provide the name in which the certificate was issued.
Middle name
Last name
First name
Suffix
Were you born on a U.S. military installation?
YES NO (If NO, proceed to Section 10)
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Est.
9.1 Complete the following if you answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide the date the document was issued.
(Month/Day/Year)
Est.
Provide your Certificate of Citizenship number.
Provide the date the certificate was issued. (Month/Day/Year)
Est.
Provide type of documentation of U.S. citizen born abroad.
FS 240 DS 1350 FS 545 Other (Provide explanation)
(Month/Day/Year) (Month/Day/Year)
Section 7 - Your Contact Information
Home e-mail address Work e-mail address
Home telephone number
Extension
International or DSN phone number
Night
Day
Work telephone number
Extension
International or DSN phone number
Night
Day
Mobile/Cell telephone number
Extension
International or DSN phone number
Night
Day
Provide the name of the base.
Provide your contact information. Email addresses may be used as a contact method, and identify subject in records.
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your
background investigation.
Page 4
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Provide the name in which the Certificate of Naturalization was issued.
Middle name
Last name
First name
Suffix
Street
Zip Code
Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)
Est.
Provide your Certificate of Naturalization number (N550 or N570).
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Enter your Social Security Number before going to the next page
(Provide explanation)
9.4 Complete the following if you answered that you are not a U.S. citizen.
Provide your date of entry in the U.S.
(Month/Day/Year)
Est.
Provide your residence status.
Provide the date document was issued
Est.
Provide your alien registration
number (I-551, I-766)
Provide the name in which the document was issued.
Middle name
Last name
First name
Suffix
Provide document expiration date.
Provide document number.
Est.
Provide the basis of naturalization.
Other
Based on my own individual naturalization application
Provide type of document issued. (I-94, U.S. Visa - red foil number, I-20, DS-2019, etc.)
I-94 U.S. Visa (red foil number) I-20 DS-2019
Other (Provide explanation)
Provide the name of the court that issued the
Certificate of Naturalization.
Section 9 - Citizenship - (Continued)
(Month/Day/Year) (Month/Day/Year)
(Month/Day/Year)
Est.
Provide the date of entry into the U.S.
State
City
Provide country(ies) of prior citizenship.
#1 Country
Provide the location of entry into the U.S.
Do/did you have a U.S. alien registration number?
Provide your U.S. alien registration number on Certificate of
Naturalization USCIS, CIS, or INS registration, I-551, I-766.
9.2 Complete the following if you answered that you are a naturalized U.S. citizen.
YES
NO
#2 Country
Provide your place of entry in the U.S.
State
City
Provide country(ies) of citizenship.
#1 Country
#2 Country
Provide your alien registration number (on Certificate of
Citizenship — utilize USCIS, CIS or INS registration number)
9.3 Complete the following if you answered that you are a derived U.S. citizen.
Provide your Permanent Resident Card
number (I-551)
Provide your Certificate of Citizenship
number (N560 or N561)
Provide the name in which the document was issued.
Middle name
Last name
First name
Suffix
(Provide explanation)
Provide the basis of derived citizenship.
Other
By operation of law through my U.S. citizen parent
Provide the date document was issued
Est.
(Month/Day/Year)
Provide document expiration
date (I-766 ONLY)
Est.
(Month/Day/Year)
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Page 5
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information
10.1 Do you now or have you EVER held dual/multiple citizenships?
YES
NO (If NO, proceed to 10.2)
Complete the following if you answered 'Yes' to having EVER held dual/multiple citizenships.
Entry #1
Provide country of citizenship.
How did you acquire this non-U.S. citizenship you now have or previously had?
During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
From Date (Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Have you taken any action to renounce your foreign citizenship?
NOYES
Provide explanation:
Do you currently hold citizenship with this country?
NOYES
Provide explanation:
Entry #2
How did you acquire this non-U.S. citizenship you now have or previously had?
During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
From Date (Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Have you taken any action to renounce your foreign citizenship?
YES NO
Provide explanation:
Provide explanation:
YES NO
Do you currently hold citizenship with this country?
Provide country of citizenship.
10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?
NO (If NO, proceed to Section 11)YES
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #1
Provide the country in which the passport (or identity card) was issued.
Provide the date the passport (or identity card) was issued. (Month/Day/Year)
Est.
Provide the place the passport (or identity card) was issued.
Provide the name in which passport (or identity card) was issued.
City Country
Last name
First name
Middle name
Suffix
Provide the passport (or identity card) number.
Provide the passport (or identity card) expiration date.
(Month/Day/Year)
Est.
Have you EVER used this passport (or identity card) for foreign travel?
NOYES
Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country From date (Month/Year) To date (Month/Year)
#1
Est. Est. Present
#2
Est. Est. Present
#3
Est. Est. Present
#4
Est. Est. Present
#5
Est. Est. Present
#6
Est. Est. Present
Enter your Social Security Number before going to the next page
Page 6
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued)
Enter your Social Security Number before going to the next page
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #2
Provide country in which the passport (or identity card) was issued.
Provide the date the passport (or identity card) was issued. (Month/Day/Year)
Est.
Provide the place the passport (or identity card) was issued.
Provide the name in which passport (or identity card) was issued.
City Country
Last name
First name
Middle name
Suffix
Provide the passport (or identity card) number.
Provide the passport (or identity card) expiration date.
(Month/Day/Year)
Est.
Have you EVER used this passport (or identity card) for foreign travel?
NOYES
Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country From date (Month/Year) To date (Month/Year)
#1
Est. Est. Present
#2
Est. Est. Present
#3
Est. Est. Present
#4
Est. Est. Present
#5
Est. Est. Present
#6
Est. Est. Present
Page 7
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived
List the places where you have lived beginning with your present residence and working back 10 years. Residences for the entire period must be accounted
for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you were not physically
located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th
birthday unless to provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew
you for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for periods of residence.
Entry #1
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Owned by you
Military housing
Rented or leased by you
Other
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Page 8
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived - (Continued)
Entry #2
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Owned by you
Military housing
Rented or leased by you
Other
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor, landlord (if rental) or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Page 9
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived - (Continued)
Entry #3
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Owned by you
Military housing
Rented or leased by you
Other
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor, landlord (if rental) or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Page 10
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived - (Continued)
Entry #4
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor, landlord (if rental) or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Owned by you
Military housing
Rented or leased by you
Other
Page 11
Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Entry #1
Section 12 - Where You Went to School
(a) Have you attended any schools in the last 10 years?
YES NO
(b) Have you received a degree or diploma more than 10 years ago?
YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
YES NO
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For
assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx
(Provide City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Did you receive a degree/diploma?
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide telephone number for this person.
I don't know
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma
Date awarded
(Month/Year)
Est.
Provide email address for this person.
(Month/Year) (Month/Year)
To Date
Entry #2
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For
assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx
(Provide City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)
Zip Code
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
(Month/Year) (Month/Year)
To Date
Day Night
Page 12
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 12 - Where You Went to School - (Continued)
YES NO
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Did you receive a degree/diploma?
Street
City
State
Country
Zip Code
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma Date awarded (Month/Year) Est.
Provide email address for this person.
Entry #2 (Continued)
Entry #3
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
YES NO
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For
assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx
(Provide City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Did you receive a degree/diploma?
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
Street
City
State
Country
Zip Code
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma Date awarded (Month/Year) Est.
Provide email address for this person.
(Month/Year) (Month/Year)
To Date
I don't know
International or DSN phone number
Telephone number
Extension
Provide telephone number for this person.
Day Night
International or DSN phone number
I don't know
Telephone number
Extension
Provide telephone number for this person.
Day Night
Page 13
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 12 - Where You Went to School - (Continued)
Entry #4
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
YES NO
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For
assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx
(Provide City and Country if outside the United States; otherwise,
provide City, State and Zip Code.)
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Did you receive a degree/diploma?
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
Street
City
State
Country
Zip Code
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma Date awarded (Month/Year) Est.
Provide email address for this person.
(Month/Year) (Month/Year)
To Date
International or DSN phone number
I don't know
Telephone number
Extension
Provide telephone number for this person.
Day Night
Page 14
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #1
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 10 years. The entire period
must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military
duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment
before your 18th birthday unless to provide a minimum of 2 years employment history.
Entry #1
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 15
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #1
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 16
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #1
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employment.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Page 17
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, 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 a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #1Entry #1Entry #1
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 18
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #2
Entry #2
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 19
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #2
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 20
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #2
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employment.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Page 21
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, 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 a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #2Entry #2Entry #2
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 22
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #3
Entry #3
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 23
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #3
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 24
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #3
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employment.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, 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 a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #3Entry #3Entry #3
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 25
Page 26
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #4
Entry #4
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 27
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #4
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 28
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #4
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employment.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Page 29
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, 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 a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #4Entry #4Entry #4
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 30
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13B - Employment Activities - Former Federal Service
YES NO (If NO, proceed to Section 13C)
Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?
Complete the following if you selected "Yes" to having former federal civilian employment, excluding military service, NOT indicated previously.
Provide your position title.
Provide the name of the federal agency for
which you are/were employed.
Street
City
State
Country
Provide the location of the agency.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #2
Section 13C - Employment Record
Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed?
- Fired from a job?
- Quit a job after being told you would be fired?
- Have you left a job by mutual agreement following charges or allegations of misconduct?
- Left a job by mutual agreement following notice of unsatisfactory performance?
- Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in
the workplace, such as violation of a security policy?
NO (If NO, proceed to Section 14)
YES (If YES, you will be required to add an additional employment in Section 13A)
Enter your Social Security Number before going to the next page
(Month/Year) (Month/Year)
Provide your position title.
Provide the name of the federal agency for
which you are/were employed.
Street
City
State
Country
Provide the location of the agency.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #1
(Month/Year) (Month/Year)
Provide your position title.
Provide the name of the federal agency for
which you are/were employed.
Street
City
State
Country
Provide the location of the agency.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #4
(Month/Year) (Month/Year)
Provide your position title.
Provide the name of the federal agency for
which you are/were employed.
Street
City
State
Country
Provide the location of the agency.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #3
(Month/Year) (Month/Year)
Page 31
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Yes
No
I don't know
Were you born a male after December 31, 1959?
Section 14 - Selective Service Record
Provide registration number:
Provide explanation:
Provide explanation:
The Selective Service website, www.sss.gov, can help provide the
registration number for persons who have registered. Note: Selective
Service Number is not your Social Security Number.
Section 15 - Military History
YES NO (If NO, proceed to Section 15.2)
Have you EVER served in the U.S. Military?
Army
Army National
Guard
Navy
Air Force
Air National
Guard
Marine Corps
Coast Guard
Provide the branch of service you served in.
15.1 Complete the following if you responded 'Yes' to having served in the U.S. Military.
State of service, if
National Guard
Enlisted
Not Applicable
Officer
Officer or enlisted
Provide your dates of service.
From Date
(Month/Year)
Est.
To Date
(Month/Year)
Present
Est.
Provide your service number.
YES NO
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
Provide the type of discharge you received:
Honorable
Dishonorable
Bad Conduct
Other (provide type)
Under Other than
Honorable Conditions
General
Provide the date of
discharge listed
(Month/Year)
Est.
Provide the reason(s) for the discharge, if discharge is other than Honorable
Have you registered with the Selective Service System (SSS)?
YES NO (If NO, proceed to Section 15)
Active Duty
Active Reserve
Inactive Reserve
Provide your status
Entry #1
Army
Army National
Guard
Navy
Air Force
Air National
Guard
Marine Corps
Coast Guard
Provide the branch of service you served in.
State of service, if
National Guard
Enlisted
Not Applicable
Officer
Officer or enlisted
Provide your dates of service.
From Date
(Month/Year)
Est.
To Date
(Month/Year)
Present
Est.
Provide your service number.
YES NO
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
Provide the type of discharge you received:
Honorable
Dishonorable
Under Other than
Honorable Conditions
General
Bad Conduct
Other (provide type)
Provide the date of
discharge listed
(Month/Year)
Est.
Provide the reason(s) for the discharge, if discharge is other than Honorable
Active Duty
Active Reserve
Inactive Reserve
Provide your status
Entry #2
Page 32
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 15 - Military History - (Continued)
YES NO (If NO, proceed to Section 15.3)
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?
Est.
Provide the date of the court martial or other disciplinary procedure.
(Month/Year)
Entry #1
Provide a description of the Uniform Code of Military Justice (UCMJ)
offense(s) for which you were charged.
Provide the name of the disciplinary procedure, such as Court Martial,
Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.
Provide the 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).
Provide the description of the final outcome of the disciplinary procedure,
such as found guilty, found not guilty, fine, reduction in rank,
imprisonment, etc.
Est.
Provide the date of the court martial or other disciplinary procedure.
(Month/Year)
Entry #2
Provide a description of the Uniform Code of Military Justice (UCMJ)
offense(s) for which you were charged.
Provide the name of the disciplinary procedure, such as Court Martial,
Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.
Provide the 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).
Provide the description of the final outcome of the disciplinary procedure,
such as found guilty, found not guilty, fine, reduction in rank,
imprisonment, etc.
Complete the following if you responded 'Yes' to 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.
15.2
Page 33
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 15 - Military History - (Continued)
YES NO (If NO, proceed to Section 16)
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?
Military (Specify Army, Navy, Air Force, Marines, etc.)
Intelligence Service
Diplomatic Service
Security Forces
Militia
Other Defense Forces
Other Government Agency,
During your foreign service, which organization were you serving under?
Complete the following if you responded 'Yes' to having 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.
Provide your period of service.
From Date
Est.
To Date
Est.
Present
(Month/Year)(Month/Year)
Provide the name of the foreign organization.
Provide the name of the country. Provide the highest position/rank held.
Provide division/department/office in which you served.
Provide a description of the reason for leaving this service.Provide a description of the circumstances of your association with this organization.
Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this organization?
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
Contact #1
From Date
Est.
To Date
Est.
Present
(Month/Year)(Month/Year)
YES NO (If NO, proceed to Section 16)
Provide the frequency of contact.
Provide the contact's official title.
15.3
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
From Date
Est.
To Date
Est.
Present
Provide the contact's official title. Provide the frequency of contact.
Contact #2
(Month/Year) (Month/Year)
Page 33
Entry #1
Specify
Page 34
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 15 - Military History - (Continued)
Military (Specify Army, Navy, Air Force, Marines, etc.)
Intelligence Service
Diplomatic Service
Security Forces
Militia
Other Defense Forces
Other Government Agency,
During your foreign service, which organization were you serving under?
Complete the following if you responded 'Yes' to having 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.
Provide your period of service.
From Date
Est.
To Date
Est.
Present
(Month/Year)(Month/Year)
Provide the name of the foreign organization.
Provide the name of the country. Provide the highest position/rank held.
Provide division/department/office in which you served.
Provide a description of the reason for leaving this service.Provide a description of the circumstances of your association with this organization.
Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this organization?
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
Contact #1
From Date
Est.
To Date
Est.
Present
(Month/Year)(Month/Year)
YES NO (If NO, Proceed to Section 16)
Provide the frequency of contact.
Provide the contact's official title.
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
From Date
Est.
To Date
Est.
Present
Provide the contact's official title. Provide the frequency of contact.
Contact #2
(Month/Year) (Month/Year)
Page 34
Entry #2
Specify
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Night
Middle name
First name
Last name
Provide e-mail address for this person.
Suffix
Provide telephone number for
this person.
International or DSN
phone number
Extension
From Date
Est.
Provide dates known.
To Date
Present
Est.
(Month/Year)(Month/Year)
Provide relationship to you. (Check all that apply)
City
Provide home or work address for this person. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
State
Country
Zip Code
Provide mobile/cell telephone
number for this person.
I don't know
Schoolmate
Other (Provide explanation)
Provide rank/title
Friend
Neighbor
Not applicable
Provide full name.
I don't know
Work associate
Day
NightDay
International or DSN
phone number
Extension
I don't know
Section 16 - People Who Know You Well
Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc.,
who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association with you covers at least
the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.
Entry #1
Night
Middle name
First name
Last name
Provide e-mail address for this person.
Suffix
Provide telephone number for
this person.
International or DSN
phone number
Extension
From Date
Est.
Provide dates known.
To Date
Present
Est.
(Month/Year)(Month/Year)
Provide relationship to you. (Check all that apply)
City
Provide home or work address for this person. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
State
Zip Code
Provide mobile/cell telephone
number for this person.
I don't know
Schoolmate
Provide rank/title
Friend
Neighbor
Not applicable
Provide full name.
I don't know
Work associate
Day
NightDay
International or DSN
phone number
Extension
I don't know
Entry #2
Night
Middle name
First name
Last name
Provide e-mail address for this person.
Suffix
Provide telephone number for
this person.
International or DSN
phone number
Extension
From Date
Est.
Provide dates known.
To Date
Present
Est.
(Month/Year)(Month/Year)
Provide relationship to you. (Check all that apply)
City
Provide home or work address for this person. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
State
Country
Zip Code
Provide mobile/cell telephone
number for this person.
I don't know
Schoolmate
Provide rank/title
Friend
Neighbor
Not applicable
Provide full name.
I don't know
Work associate
Day
NightDay
International or DSN
phone number
Extension
I don't know
Entry #3
Country
Other (Provide explanation)
Other (Provide explanation)
Page 35
Page 36
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Country #1
Provide date when you entered into your civil
marriage, civil union, or domestic partnership.
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Country #2
Provide country(ies) of citizenship.
Section 17 - Marital/Relationship Status
Divorced/Dissolved (Complete 17.2 and 17.3)
Separated (Complete 17.1 and 17.3)
Annulled (Complete 17.2 and 17.3)
Currently in a civil marriage, legally recognized civil union, or legally
recognized domestic partnership (Complete 17.1 and 17.3)
Never entered in a civil marriage, legally recognized civil union, or legally
recognized domestic partnership (Complete 17.3)
Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic partnership:
Widowed (Complete 17.2 and 17.3)
Middle name
Provide date of birth.
SuffixLast name First name
Est.
Provide full name.
(Month/Day/Year)
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
I-766 Employment
Authorization
I-551 Permanent ResidentFS 240 or 545
If the person is foreign born, provide one type of documentation that he or she possesses and the document number.
Other (Provide explanation)
Provide U.S. Social Security Number.
Provide document number.
Not applicable
Provide place of birth.
City
County
State
Country
(required)
17.1 Complete the following if you selected “currently in a civil marriage,” “legally recognized civil union," or "legally recognized domestic
partnership” or “Separated.” Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally
recognized domestic partnership, or the person from whom you are currently separated.
Not applicable
Provide other names used (such as maiden name, names by other marriages, civil marriages, legally recognized
civil unions, or legally recognized domestic partnerships, nicknames, etc., and provide dates used for each name).
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Born Abroad to U.S. Parents:
Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide document expiration date, if applicable.
(Month/Day/Year)
Est.
(Month/Day/Year)
Est.
Page 37
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
NO
YES
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/
fleet headquarter.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Zip Code
Provide date of separation.
(Month/Day/Year)
Est.
Provide location. (
Provide City and Country if outside the United States; otherwise, provide City or County and State.)
City
County
State
Country
Provide telephone number.
Extension
Provide email address.
Use my current telephone number
International or DSN phone number
Provide current address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Are you separated?
City
State
Country
If legally separated, provide the location of the record.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Zip Code
Not Applicable
Day
Night
Section 17 - Marital/Relationship Status - (Continued)
17.1 Complete the following if you selected “currently in a civil marriage,” “legally recognized civil union," or "legally recognized domestic
partnership” or “Separated.” Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally
recognized domestic partnership, or the person from whom you are currently separated. (Continued)
Use my current address
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person have an APO/FPO address within the United States?
YES
NO
Page 38
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, complete (a)) I don't know
Est.
Provide the country(ies) of citizenship.
Country #1
Country #2
Middle name
Provide the date of birth.
(Month/Day/Year)
SuffixLast name First name
Est.
Provide the full name.
Entry #1
Provide the place of birth.
City State
Country
(Required)
Zip Code
17.2 Complete the following if you selected "divorced/dissolved", "annulled", or "widowed". Provide information about any person from whom you are
divorced/dissolved, annulled, or widowed.
Provide the location. (
Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
City State
Country
Section 17 - Marital/Relationship Status - (Continued)
AnnulledWidowedDivorced/Dissolved
Provide the status.
Provide where the record of divorce/dissolution or annulment is located. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City State
Country
Zip Code
Is this person deceased?
Provide last known address of the person from whom you are divorced/dissolved or annulled. (
Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(a)
Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)
Est.
I don't
know
Provide telephone number.
Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)
Page 39
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, complete (a)) I don't know
Est.
Provide the country(ies) of citizenship.
Country #1
Country #2
Middle name
Provide the date of birth.
(Month/Day/Year)
SuffixLast name First name
Est.
Provide the full name.
Entry #2
Provide the place of birth.
City State
Country
(Required)
Zip Code
17.2 Complete the following if you selected "divorced/dissolved", "annulled", or "widowed". Provide information about any person from whom you are
divorced/dissolved, annulled, or widowed.
Provide the location. (
Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
City State
Country
Section 17 - Marital/Relationship Status - (Continued)
AnnulledWidowedDivorced/Dissolved
Provide the status.
Provide where the record of divorce/dissolution or annulment is located. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City State
Country
Zip Code
Is this person deceased?
Provide last known address of the person from whom you are divorced/dissolved or annulled. (
Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(a)
Provide the date divorced, annulled or widowed. (Month/Day/Year)
Est.
I don't
know
Provide telephone number.
Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)
Page 40
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 18)
Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic
partner, with whom you share bonds of affection, obligation, or other commitment, as opposed to a
person with whom you live for reasons of convenience (e.g. a roommate)? If so, complete the following.
If the person was born outside the U.S., provide citizenship information.
(Month/Day/Year)
17.3
Complete the following if you presently reside with a cohabitant.
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Country #1
Provide date cohabitation residing with
person began.
(Month/Day/Year)
Country #2
Provide your cohabitant's country(ies) of citizenship.
Entry #1
Middle name
Provide the date of birth.
Suffix
Last name First name
Est.
Provide the cohabitant full name.
Date
Provide the place of birth.
City State
Country
(Required)
Section 17 - Marital/Relationship Status - (Continued)
Not applicable
Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each
name was used).
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Provide document number.
Not applicable
Certificate of Naturalization
(N550 or N570)
Provide document expiration date, if applicable.
(Month/Day/Year)
Est.
Provide your cohabitant's U.S. Social Security Number.
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
I-766 Employment
Authorization
I-551 Permanent ResidentFS 240 or 545
For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.
Other (Provide explanation)
Born Abroad to U.S. Parents:
Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Citizenship (N560
or N561)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Page 41
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
(Month/Day/Year)
Complete the following if you presently reside with a cohabitant.
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Country #1
Provide date cohabitation residing with
person began.
(Month/Day/Year)
Country #2
Provide your cohabitant's country(ies) of citizenship.
Entry #2
Middle name
Provide the date of birth.
Suffix
Last name First name
Est.
Provide the cohabitant full name.
Date
Provide the place of birth.
City State
Country
(Required)
Section 17 - Marital/Relationship Status - (Continued)
Not applicable
Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each
name was used).
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
NOYES
Provide document number.
Not applicable
Provide document expiration date, if applicable.
(Month/Day/Year)
Est.
Provide your cohabitant's U.S. Social Security Number.
Certificate of Naturalization
(N550 or N570)
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
I-766 Employment
Authorization
I-551 Permanent ResidentFS 240 or 545
For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.
Other (Provide explanation)
Born Abroad to U.S. Parents:
Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Citizenship (N560
or N561)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Page 42
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Has this relative used any other names?
NOYES
Not applicable
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
City
State
Country
(Required)
Provide your relative's place of birth.
Middle nameLast name
Provide your relative's full name.
Suffix
First name
Suffix
Middle name
Last name
First name
If mother, provide your mother's maiden name.
Same as listed
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
I don't know
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide relative type.
Country #1
Country #2
Provide your relative's country(ies) of citizenship.
Provide your relative's date of birth.
Est.
Date
(Month/Day/Year)
Father Child (including adopted/foster)
Stepchild
Foster parent
Stepmother
Mother
Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.)
Check all that apply.
Section 18 - Relatives
Stepfather Brother
Sister
Stepbrother
Stepsister
Half-brother
Father-in-law
Half-sister
Mother-in-law
Guardian
Entry #1
Entry #1
Page 43
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Street
Zip Code
Provide your relative's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide your relative's APO/FPO address.
YES
NO
I don't know
Is your relative deceased?
YES (If YES, proceed to 18.3) NO
Zip Code
Does this relative have an APO/FPO address?
Address
APO or FPO
APO/FPO State Code
Street
City
State
Country
Zip Code
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased.
OR
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen,
foreign born and has a U.S. or APO/FPO address.
18.3
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Entry #1 Entry #1
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
FS 240 or 545
Provide one type of citizenship documentation and document number below:
Other (Provide explanation)Born Abroad to U.S. Parents: Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Provide document number.
Provide the name of the court that issued the Certificate of Naturalization.
Page 44
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a foreign address and is not deceased.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City
and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
NO
YES
I don't know
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of first contact. (Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Present
Est.
Entry #1
I-766 Employment
Authorization
I-551 Permanent Resident Other (Provide explanation)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide document number
Provide type of documentation he or she possesses to support U.S. residence.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a U.S. address and is not deceased.
18.4
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
I don't know
YES
NO
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of
first contact. (Month/Year)
Est.
Present
Est.
Entry #1
Status:
Provide approximate date of
last contact.
(Month/Year)
Est.
Provide document expiration
date.
(Month/Day/Year)
Page 45
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Has this relative used any other names?
NOYES
Not applicable
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
City
State
Country
(Required)
Provide your relative's place of birth.
Middle nameLast name
Provide your relative's full name.
Suffix
First name
Suffix
Middle name
Last name
First name
If mother, provide your mother's maiden name.
Same as listed
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
I don't know
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide relative type.
Country #1
Country #2
Provide your relative's country(ies) of citizenship.
Provide your relative's date of birth.
Est.
Date
(Month/Day/Year)
Section 18 - Relatives - (Continued)
Entry #2
Entry #2
Page 46
Enter your Social Security Number before going to the next page
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Street
Zip Code
Provide your relative's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide your relative's APO/FPO address.
YES
NO
I don't know
Is your relative deceased?
YES (If YES, proceed to 18.3) NO
Zip Code
Does this relative have an APO/FPO address?
Address
APO or FPO
APO/FPO State Code
Street
City
State
Country
Zip Code
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased.
OR
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen,
foreign born and has a U.S. or APO/FPO address.
18.3
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Entry #2 Entry #2
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
FS 240 or 545
Provide one type of citizenship documentation and document number below:
Other (Provide explanation)Born Abroad to U.S. Parents: Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Provide document number.
Provide the name of the court that issued the Certificate of Naturalization.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Page 47
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a foreign address and is not deceased.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City
and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
NO
YES
I don't know
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of first contact. (Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Present
Est.
Entry #2
I-766 Employment
Authorization
I-551 Permanent Resident Other (Provide explanation)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide type of documentation he or she possesses to support U.S. residence.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a U.S. address and is not deceased.
18.4
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
I don't know
YES
NO
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of
first contact. (Month/Year)
Est.
Present
Est.
Entry #2
Status:
Provide approximate date of
last contact.
(Month/Year)
Provide document number
Est.
Provide document expiration
date.
(Month/Day/Year)
Page 48
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Has this relative used any other names?
NOYES
Not applicable
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
City
State
Country
(Required)
Provide your relative's place of birth.
Middle nameLast name
Provide your relative's full name.
Suffix
First name
Suffix
Middle name
Last name
First name
If mother, provide your mother's maiden name.
Same as listed
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
I don't know
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide relative type.
Country #1
Country #2
Provide your relative's country(ies) of citizenship.
Provide your relative's date of birth.
Est.
Date
(Month/Day/Year)
Section 18 - Relatives - (Continued)
Entry #3
Entry #3
Page 49
Enter your Social Security Number before going to the next page
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Street
Zip Code
Provide your relative's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide your relative's APO/FPO address.
YES
NO
I don't know
Is your relative deceased?
YES (If YES, proceed to 18.3) NO
Zip Code
Does this relative have an APO/FPO address?
Address
APO or FPO
APO/FPO State Code
Street
City
State
Country
Zip Code
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased.
OR
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen,
foreign born and has a U.S. or APO/FPO address.
18.3
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Entry #3 Entry #3
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
FS 240 or 545
Provide one type of citizenship documentation and document number below:
Other (Provide explanation)Born Abroad to U.S. Parents: Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Provide document number.
Provide the name of the court that issued the Certificate of Naturalization.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Page 50
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a foreign address and is not deceased.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City
and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
NO
YES
I don't know
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of first contact. (Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Present
Est.
Entry #3
I-766 Employment
Authorization
I-551 Permanent Resident Other (Provide explanation)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide type of documentation he or she possesses to support U.S. residence.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a U.S. address and is not deceased.
18.4
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
I don't know
YES
NO
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of
first contact. (Month/Year)
Est.
Present
Est.
Entry #3
Status:
Provide approximate date of
last contact.
(Month/Year)
Provide document number
Est.
Provide document expiration
date.
(Month/Day/Year)
Page 51
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Has this relative used any other names?
NOYES
Not applicable
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
City
State
Country
(Required)
Provide your relative's place of birth.
Middle nameLast name
Provide your relative's full name.
Suffix
First name
Suffix
Middle name
Last name
First name
If mother, provide your mother's maiden name.
Same as listed
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
I don't know
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide relative type.
Country #1
Country #2
Provide your relative's country(ies) of citizenship.
Provide your relative's date of birth.
Est.
Date
(Month/Day/Year)
Section 18 - Relatives - (Continued)
Entry #4
Entry #4
Page 52
Enter your Social Security Number before going to the next page
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Street
Zip Code
Provide your relative's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide your relative's APO/FPO address.
YES
NO
I don't know
Is your relative deceased?
YES (If YES, proceed to 18.3) NO
Zip Code
Does this relative have an APO/FPO address?
Address
APO or FPO
APO/FPO State Code
Street
City
State
Country
Zip Code
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased.
OR
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen,
foreign born and has a U.S. or APO/FPO address.
18.3
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Entry #4 Entry #4
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
FS 240 or 545
Provide one type of citizenship documentation and document number below:
Other (Provide explanation)Born Abroad to U.S. Parents: Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Provide document number.
Provide the name of the court that issued the Certificate of Naturalization.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Page 53
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a foreign address and is not deceased.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City
and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
NO
YES
I don't know
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of first contact. (Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Present
Est.
Entry #4
I-766 Employment
Authorization
I-551 Permanent Resident Other (Provide explanation)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide type of documentation he or she possesses to support U.S. residence.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a U.S. address and is not deceased.
18.4
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
I don't know
YES
NO
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of
first contact. (Month/Year)
Est.
Present
Est.
Entry #4
Status:
Provide approximate date of
last contact.
(Month/Year)
Provide document number
Est.
Provide document expiration
date.
(Month/Day/Year)
Page 54
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Has this relative used any other names?
NOYES
Not applicable
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
City
State
Country
(Required)
Provide your relative's place of birth.
Middle nameLast name
Provide your relative's full name.
Suffix
First name
Suffix
Middle name
Last name
First name
If mother, provide your mother's maiden name.
Same as listed
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
I don't know
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide relative type.
Country #1
Country #2
Provide your relative's country(ies) of citizenship.
Provide your relative's date of birth.
Est.
Date
(Month/Day/Year)
Section 18 - Relatives - (Continued)
Entry #5
Entry #5
Page 55
Enter your Social Security Number before going to the next page
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Street
Zip Code
Provide your relative's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide your relative's APO/FPO address.
YES
NO
I don't know
Is your relative deceased?
YES (If YES, proceed to 18.3) NO
Zip Code
Does this relative have an APO/FPO address?
Address
APO or FPO
APO/FPO State Code
Street
City
State
Country
Zip Code
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased.
OR
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen,
foreign born and has a U.S. or APO/FPO address.
18.3
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Entry #5 Entry #5
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
FS 240 or 545
Provide one type of citizenship documentation and document number below:
Other (Provide explanation)Born Abroad to U.S. Parents: Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Provide document number.
Provide the name of the court that issued the Certificate of Naturalization.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Page 56
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a foreign address and is not deceased.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City
and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
NO
YES
I don't know
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of first contact. (Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Present
Est.
Entry #5
I-766 Employment
Authorization
I-551 Permanent Resident Other (Provide explanation)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide type of documentation he or she possesses to support U.S. residence.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a U.S. address and is not deceased.
18.4
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
I don't know
YES
NO
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of
first contact. (Month/Year)
Est.
Present
Est.
Entry #5
Status:
Provide approximate date of
last contact.
(Month/Year)
Provide document number
Est.
Provide document expiration
date.
(Month/Day/Year)
Page 57
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Has this relative used any other names?
NOYES
Not applicable
Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former
name, alias, or nickname).
City
State
Country
(Required)
Provide your relative's place of birth.
Middle nameLast name
Provide your relative's full name.
Suffix
First name
Suffix
Middle name
Last name
First name
If mother, provide your mother's maiden name.
Same as listed
18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister.
I don't know
Middle nameFirst name
Last name
#1
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#2
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#3
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Middle nameFirst name
Last name
#4
From
(Month/Year) To (Month/Year)
Suffix
Est. Est.
Present
Maiden name?
YES NO
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide the reason(s) why the name changed.
Provide relative type.
Country #1
Country #2
Provide your relative's country(ies) of citizenship.
Provide your relative's date of birth.
Est.
Date
(Month/Day/Year)
Section 18 - Relatives - (Continued)
Entry #6
Entry #6
Page 58
Enter your Social Security Number before going to the next page
Provide the address of the court that issued the Certificate of Naturalization.
State
City
Street
Zip Code
Provide your relative's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Provide your relative's APO/FPO address.
YES
NO
I don't know
Is your relative deceased?
YES (If YES, proceed to 18.3) NO
Zip Code
Does this relative have an APO/FPO address?
Address
APO or FPO
APO/FPO State Code
Street
City
State
Country
Zip Code
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,
Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased.
OR
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen,
foreign born and has a U.S. or APO/FPO address.
18.3
18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.
Entry #6 Entry #6
DS 1350
Alien Registration (on Certificate
of Naturalization—utilize USCIS,
CIS or INS Registration number)
FS 240 or 545
Provide one type of citizenship documentation and document number below:
Other (Provide explanation)Born Abroad to U.S. Parents: Naturalized:
Permanent Resident Card (I-551)
Derived:
Alien Registration (on Certificate
of Citizenship—utilize USCIS,
CIS or INS Registration number)
Permanent Resident Card (I-551)
Certificate of Naturalization
(N550 or N570)
Certificate of Citizenship (N560
or N561)
Provide document number.
Provide the name of the court that issued the Certificate of Naturalization.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Page 59
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 18 - Relatives - (Continued)
Enter your Social Security Number before going to the next page
18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a foreign address and is not deceased.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City
and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
NO
YES
I don't know
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of first contact. (Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Present
Est.
Entry #6
I-766 Employment
Authorization
I-551 Permanent Resident Other (Provide explanation)
Not a U.S. Citizen:
U.S. Visa (red foil number)
I-20 Certificate of Eligibility for
Non-Immigrant-F1-Student
DS-2019 Certificate of Eligibility
of Exchange Visitor-J1-Status
I-94 Arrival-Departure Record
Provide type of documentation he or she possesses to support U.S. residence.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence Other
Provide approximate frequency of contact.
Monthly Annually
Daily
Weekly (Provide explanation)Other Quarterly
Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).
Employer name
I don't know
Provide the address of current employer, or provide the address of their most recent employer if not currently employed.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
I don't know
Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster),
Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen,
has a U.S. address and is not deceased.
18.4
(Provide explanation)
Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?
I don't know
YES
NO
Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence
service.
Provide approximate date of
first contact. (Month/Year)
Est.
Present
Est.
Entry #6
Status:
Provide approximate date of
last contact.
(Month/Year)
Provide document number
Est.
Provide document expiration
date.
(Month/Day/Year)
Page 60
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
NO (If NO, proceed
to Section 20A)
YES
Provide place of birth.
I don't know
Provide country(ies) of citizenship.
Country #1
Country #2
Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.
Section 19 - Foreign Contacts
Do you have, or have you had, close and/or continuing contact with a foreign national within the last seven (7) years with
whom you, or your spouse, or legally recognized civil union/domestic partner, or cohabitant are bound by affection,
influence, common interests, and/or obligation? Include associates as well as relatives, not previously listed in Section 18.
A foreign national is defined as any person who is not a citizen or national of the U.S.
Entry #1
I don't know
Suffix
Middle name
Last name
First name
Explanation if name is unknown
Provide the full name of the foreign national, if known.
Provide approximate date of first contact.
(Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Est.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence (Provide explanation)Other
Daily
Weekly
Monthly
Quarterly
Annually
Other (Provide explanation)
Provide the nature of relationship (Check all that apply).
(Provide explanation)
Other
Personal (Such as family ties, friendship, affection, common interests, etc)Professional or Business
(Provide explanation)
Obligation
Last name First name Middle name Suffix
Provide other names and/or nicknames, as appropriate.
Est.
Provide date of birth.
(Month/Day/Year)
I don't know
Provide current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.
Employer name
I don't know
Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently
employed. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?
YES
NO I don't know
Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.
Zip Code
NO
YES
I don't know
Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.
Address
APO or FPO
APO/FPO State Code
Country (If country unknown, requires explanation)City
Provide approximate frequency of contact.
Page 61
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Provide place of birth.
I don't know
Provide country(ies) of citizenship.
Country #1
Country #2
I don't know
Suffix
Middle name
Last name
First name
Explanation if name is unknown
Provide the full name of the foreign national, if known.
Provide approximate date of first contact.
(Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Est.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence (Provide explanation)Other
Daily
Weekly
Monthly
Quarterly
Annually
Other (Provide explanation)
Provide the nature of relationship (Check all that apply).
(Provide explanation)
Other
Personal (Such as family ties, friendship, affection, common interests, etc)
Professional or Business
(Provide explanation)
Obligation
Last name First name Middle name Suffix
Provide other names and/or nicknames, as appropriate.
Est.
Provide date of birth.
(Month/Day/Year)
I don't know
Provide current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.
Employer name
I don't know
Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently
employed. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?
NO
YES
I don't know
Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.
NO
YES
I don't know
Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.
Country (If country unknown, requires explanation)City
Provide approximate frequency of contact.
Zip CodeAddress
APO or FPO
APO/FPO State Code
Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.
Section 19 - Foreign Contacts - (Continued)
Entry #2
Page 62
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Provide place of birth.
I don't know
Provide country(ies) of citizenship.
Country #1
Country #2
I don't know
Suffix
Middle name
Last name
First name
Explanation if name is unknown
Provide the full name of the foreign national, if known.
Provide approximate date of first contact.
(Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Est.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence (Provide explanation)Other
Daily
Weekly
Monthly
Quarterly
Annually
Other (Provide explanation)
Provide the nature of relationship (Check all that apply).
(Provide explanation)
Other
Personal (Such as family ties, friendship, affection, common interests, etc)
Professional or Business
(Provide explanation)
Obligation
Last name First name Middle name Suffix
Provide other names and/or nicknames, as appropriate.
Est.
Provide date of birth.
(Month/Day/Year)
I don't know
Provide current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.
Employer name
I don't know
Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently
employed. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?
NO
YES
I don't know
Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.
NO
YES
I don't know
Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.
Country (If country unknown, requires explanation)City
Provide approximate frequency of contact.
Zip Code
Address
APO or FPO
APO/FPO State Code
Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.
Section 19 - Foreign Contacts - (Continued)
Entry #3
Page 63
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Provide place of birth.
I don't know
Provide country(ies) of citizenship.
Country #1
Country #2
I don't know
Suffix
Middle name
Last name
First name
Explanation if name is unknown
Provide the full name of the foreign national, if known.
Provide approximate date of first contact.
(Month/Year)
Est.
Provide approximate date of last contact. (Month/Year)
Est.
Provide methods of contact (Check all that apply).
Telephone Electronic (Such as e-mail, texting, chat rooms, etc)In person
Written correspondence (Provide explanation)Other
Daily
Weekly
Monthly
Quarterly
Annually
Other (Provide explanation)
Provide the nature of relationship (Check all that apply).
(Provide explanation)
Other
Personal (Such as family ties, friendship, affection, common interests, etc)
Professional or Business
(Provide explanation)
Obligation
Last name First name Middle name Suffix
Provide other names and/or nicknames, as appropriate.
Est.
Provide date of birth.
(Month/Day/Year)
I don't know
Provide current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.
Employer name
I don't know
Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently
employed. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
I don't know
Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?
NO
YES
I don't know
Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.
NO
YES
I don't know
Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.
Country (If country unknown, requires explanation)City
Provide approximate frequency of contact.
Zip Code
Address
APO or FPO
APO/FPO State Code
Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.
Section 19 - Foreign Contacts - (Continued)
Entry #4
Page 64
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to 20A.2)
20A.1
Section 20A - Foreign Activities
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
EVER had any foreign financial interests (such as stocks, property, investments, bank accounts, ownership of
corporate entities, corporate interests or exchange traded funds (ETFs) held in specific geographical or
economic sectors) in which you or they have direct control or direct ownership? (Exclude financial interests in
companies or diversified mutual funds or diversified ETFs that are publicly traded on a U.S. exchange.)
Entry #1
Provide how the financial interest was acquired (such as purchase, gift, etc.).
Country #1 Country #2
Provide your co-owner's country(ies) of citizenship.
Country #1
Country #2
Provide your co-owner's country(ies) of citizenship.
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
SuffixMiddle nameLast name First name
Provide the nature of your relationship with the co-owner.
Provide the date acquired. (Month/Day/Year)
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
having EVER had any foreign financial interests (such as stocks, property, investments, bank accounts, ownership of corporate entities, ownership of
corporate entities, corporate interests or exchange traded funds (ETFs) held in specific geographical or economic sectors) in which you or they have
direct control or direct ownership (Exclude financial interests in companies or diversified mutual funds or diversified ETFs that are publicly traded on a
U.S. exchange.)
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partnerYourself
Specify (Check all that apply):
Provide the type of financial interest.
Provide the cost (in U.S. dollars) at time of
acquisition.
Est.
Provide the current value (in U.S. dollars) or the value at the time control or
ownership was sold, lost or otherwise disposed of:
Est.
Est.
Date
Not Applicable
Provide explanation of how interest control or ownership was sold, lost or
otherwise disposed of.
Provide the date control or ownership was relinquished. (Month/Day/Year)
Are there any co-owners of this foreign financial interest?
YES NO
Provide full name of co-owner.
#1
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide full name of co-owner.
SuffixMiddle nameLast name First name
Provide the nature of your relationship with the co-owner.
#2
Est.
Page 65
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20A - Foreign Activities (Continued)
Entry #2
Provide how the financial interest was acquired (such as purchase, gift, etc.).
Country #1 Country #2
Provide your co-owner's country(ies) of citizenship.
Country #1
Country #2
Provide your co-owner's country(ies) of citizenship.
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
SuffixMiddle nameLast name First name
Provide the nature of your relationship with the co-owner.
Provide the date acquired. (Month/Day/Year)
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
having EVER had any foreign financial interests (such as stocks, property, investments, bank accounts, ownership of corporate entities, ownership of
corporate entities, corporate interests or exchange traded funds (ETFs) held in specific geographical or economic sectors) in which you or they have
direct control or direct ownership (Exclude financial interests in companies or diversified mutual funds or diversified ETFs that are publicly traded on a
U.S. exchange.)
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partnerYourself
Specify (Check all that apply):
Provide the type of financial interest.
Provide the cost (in U.S. dollars) at time of
acquisition.
Est.
Provide the current value (in U.S. dollars) or the value at the time control or
ownership was sold, lost or otherwise disposed of:
Est.
Est.
Date
Not Applicable
Provide explanation of how interest control or ownership was sold, lost or
otherwise disposed of.
Provide the date control or ownership was relinquished. (Month/Day/Year)
Are there any co-owners of this foreign financial interest?
YES NO
Provide full name of co-owner.
#1
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide full name of co-owner.
SuffixMiddle nameLast name First name
Provide the nature of your relationship with the co-owner.
#2
Est.
Page 66
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO
Est.
Provide details regarding how the financial interest was acquired (such as
purchase, gift, etc.).
First name
Provide the name of the individual who controls this financial interest on your behalf.
Last name
Provide this individual's
relationship to you.
Provide the date this financial interest
was acquired. (Month/Day/Year)
Provide your relationship with the co-owner.
SuffixMiddle name
Last name First name
Provide the full name of co-owner.#2
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
20A.2
Entry #1
NO (If NO, Proceed to 20A.3)YES
Country #1
Country #2
Provide the co-owner's country(ies) of citizenship.
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children having
EVER had any foreign financial interests that someone controlled on your behalf.
Section 20A - Foreign Activities - (Continued)
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent
children EVER had any foreign financial interests that someone controlled on your behalf?
Yourself
Specify: (Check all that apply):
Provide the type of financial
interest.
Est.
Are there any co-owners of this foreign financial interest controlled on your behalf?
Provide the full name of co-owner.
Provide your relationship with the co-owner.
SuffixMiddle name
Last name First name
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Country #1 Country #2
Provide the co-owner's country(ies) of citizenship.
#1
Provide the current value (in U.S. dollars) or
value at the time interest was sold, lost or
otherwise disposed of.
Est.
Est.
Provide the date interest was
sold, lost, or other wise disposed
of.
(Month/Day/Year)
Not Applicable
Provide explanation if interest was sold, lost
or otherwise disposed of.
Provide the cost (in U.S. dollars)
at time of acquisition.
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partner
Page 67
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20A - Foreign Activities - (Continued)
YES NO
Est.
Provide details regarding how the financial interest was acquired (such as
purchase, gift, etc.).
First name
Provide the name of the individual who controls this financial interest on your behalf.
Last name
Provide this individual's
relationship to you.
Provide the date this financial interest
was acquired. (Month/Day/Year)
Provide your relationship with the co-owner.
SuffixMiddle name
Last name First name
Provide the full name of co-owner.#2
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Entry #2
Country #1 Country #2
Provide the co-owner's country(ies) of citizenship.
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children having
EVER had any foreign financial interests that someone controlled on your behalf.
Yourself
Specify: (Check all that apply):
Provide the type of financial
interest.
Est.
Are there any co-owners of this foreign financial interest controlled on your behalf?
Provide the full name of co-owner.
Provide your relationship with the co-owner.
SuffixMiddle name
Last name First name
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Country #1 Country #2
Provide the co-owner's country(ies) of citizenship.
#1
Provide the current value (in U.S. dollars) or
value at the time interest was sold, lost or
otherwise disposed of.
Est.
Est.
Provide the date interest was
sold, lost, or other wise disposed
of.
(Month/Day/Year)
Not Applicable
Provide explanation if interest was sold, lost
or otherwise disposed of.
Provide the cost (in U.S. dollars)
at time of acquisition.
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partner
Page 68
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
SuffixMiddle nameLast name First name
Provide the full name of co-owner.
#1
Provide the co-owner's current address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO
YES NO (If NO, Proceed to 20A.4)
Est.
Provide the date of purchase or
to be acquired.
(Month/Day/Year)
SuffixMiddle nameLast name First name
Provide the full name of co-owner.
#2
Provide the co-owner's current address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide the nature of your relationship with the co-owner.
Entry #1
Country #1
Country #2
Provide the co-owner's country(ies) of citizenship.
Provide the nature of your relationship with the co-owner.Country #1 Country #2
Provide the co-owner's country(ies) of citizenship.
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
EVER owned, or do you anticipate owning, or plan to purchase real estate in a foreign country.
Section 20A - Foreign Activities - (Continued)
20A.3
Yourself
Specify (Check all that apply):
Provide the type of real estate property
(such as home, business, etc.).
Provide how the foreign real estate was or is to be acquired (such as
purchase, gift, etc.).
Provide the cost (in U.S. dollars) when sold or expected at time of acquisition.
Est.
Are/were/will there any co-owners of this foreign real estate?
Country
Provide the location/address of property.
City
Street
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent
children EVER owned, or do you anticipate owning, or plan to purchase real estate in a foreign country?
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partner
Est.
Provide the date sold, if
applicable.
(Month/Day/Year)
Page 69
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20A - Foreign Activities - (Continued)
SuffixMiddle nameLast name First name
Provide the full name of co-owner.
#1
Provide the co-owner's current address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO
Est.
Provide the date of purchase or
to be acquired. (Month/Day/Year)
SuffixMiddle nameLast name First name
Provide the full name of co-owner.
#2
Provide the co-owner's current address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide the nature of your relationship with the co-owner.
Entry #2
Country #1
Country #2
Provide the co-owner's country(ies) of citizenship.
Provide the nature of your relationship with the co-owner.Country #1 Country #2
Provide the co-owner's country(ies) of citizenship.
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children
EVER owned, or do you anticipate owning, or plan to purchase real estate in a foreign country.
Yourself
Specify (Check all that apply):
Provide the type of real estate property
(such as home, business, etc.).
Provide how the foreign real estate was or is to be acquired (such as
purchase, gift, etc.).
Provide the cost (in U.S. dollars) when sold or expected at time of acquisition.
Est.
Are/were/will there any co-owners of this foreign real estate?
Country
Provide the location/address of property.
City
Street
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partner
Est.
Provide the date sold, if
applicable.
(Month/Day/Year)
Page 70
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
NO
YES
YES NO (If NO, Proceed to 20A.5)
20A.4
(a)
(b)
(c)
Entry #1
Complete the following if you responded 'Yes' that as a U.S. citizen, have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or
dependent children received in the last seven (7) years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other
such benefit from a foreign country.
Section 20A - Foreign Activities - (Continued)
As a U.S. citizen, have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or
dependent children received in the last seven (7) years, or are eligible to receive in the future, any
educational, medical, retirement, social welfare, or other such benefit from a foreign country?
Yourself
Specify (Check all that apply)
If you have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children received a onetime
benefit from a foreign country:
If yes, provide explanation.
Provide the type of benefit.
(Provide explanation)
Onetime benefit (Complete (a)) Future benefit (Complete (b)) Continuing benefit (Complete (c))
Other (Complete (c))
Provide the frequency of the
benefit.
(Provide explanation)
Est.
Provide the total value (in U.S.
dollars) of the benefit received.
Est.
Provide the reason this benefit
was received.
Provide the name of the country
providing the benefit.
As a result of this benefit are you, your spouse or legally recognized civil union/domestic partner, your cohabitant, or dependant children obligated in any
way to this foreign country?
If you have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children expect to receive a
benefit from a foreign country:
Provide the name of the country providing this benefit.
If yes, provide explanation.
NO
YES
As a result of this benefit are you, your spouse or legally recognized civil union/domestic partner, your cohabitant, or dependant children obligated in any
way to this foreign country?
Provide the date the benefit will
begin. (Month/Day/Year)
Est.
Provide the value (in U.S. dollars) of the
benefit to be received.
Est.
Provide the reason this benefit will
be received.
Annually
Quarterly
Monthly Other
Weekly
(Provide explanation)
Provide the frequency the benefit will be received.
If have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children receive a continuing or other
benefit from a foreign country:
Provide the name of the country providing
this benefit.
If yes, provide explanation.
NO
YES
As a result of this benefit are you, your spouse or legally recognized civil union/domestic partner, your cohabitant, or dependant children obligated in any
way to this foreign country?
Provide the date the benefit began. (Month/Day/Year)
Est.
Provide the total value (in U.S. dollars)
of benefit.
Est.
Provide the reason this benefit is
being received.
Annually
Quarterly
Monthly
Weekly
Other (Provide explanation)
Provide the frequency that this benefit is received.
Provide the date the benefit is expected to end. (Month/Day/Year)
Est.
Provide the date the benefit
was received. (Month/Day/Year)
Educational Medical Retirement Social Welfare
Other such benefit
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partner
Page 71
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20A - Foreign Activities - (Continued)
NO
YES
(a)
(b)
(c)
Entry #2
Complete the following if you responded 'Yes' that as a U.S. citizen, have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or
dependent children received in the last seven (7) years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other
such benefit from a foreign country.
Yourself
Specify (Check all that apply)
If you have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children received a onetime
benefit from a foreign country:
If yes, provide explanation.
Provide the type of benefit.
(Provide explanation)
Onetime benefit (Complete (a)) Future benefit (Complete (b)) Continuing benefit (Complete (c))
Other (Complete (c))
Provide the frequency of the
benefit.
(Provide explanation)
Est.
Provide the total value (in U.S.
dollars) of the benefit received.
Est.
Provide the reason this benefit
was received.
Provide the name of the country
providing the benefit.
As a result of this benefit are you, your spouse or legally recognized civil union/domestic partner, your cohabitant, or dependant children obligated in any
way to this foreign country?
If you have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children expect to receive a
benefit from a foreign country:
Provide the name of the country providing this benefit.
If yes, provide explanation.
NO
YES
As a result of this benefit are you, your spouse or legally recognized civil union/domestic partner, your cohabitant, or dependant children obligated in any
way to this foreign country?
Provide the date the benefit will
begin. (Month/Day/Year)
Est.
Provide the value (in U.S. dollars) of the
benefit to be received.
Est.
Provide the reason this benefit will
be received.
Annually
Quarterly
Monthly Other
Weekly
(Provide explanation)
Provide the frequency the benefit will be received.
If have indicated that you, your spouse or legally recognized civil union/domestic partner, cohabitant, or dependent children receive a continuing or other
benefit from a foreign country:
Provide the name of the country providing
this benefit.
If yes, provide explanation.
NO
YES
As a result of this benefit are you, your spouse or legally recognized civil union/domestic partner, your cohabitant, or dependant children obligated in any
way to this foreign country?
Provide the date the benefit began. (Month/Day/Year)
Est.
Provide the total value (in U.S. dollars)
of benefit.
Est.
Provide the reason this benefit is
being received.
Annually
Quarterly
Monthly
Weekly
Other (Provide explanation)
Provide the frequency that this benefit is received.
Provide the date the benefit is expected to end. (Month/Day/Year)
Est.
Provide the date the benefit
was received. (Month/Day/Year)
Educational Medical Retirement Social Welfare
Other such benefit
Dependent childrenCohabitantSpouse or legally recognized civil union/domestic partner
Page 72
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Provide the name of the foreign national you support or have supported financially.
Provide the address of the foreign national listed above.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the nature of your relationship with the foreign national listed above.
Est.
Provide the frequency of your support.
Provide the amount (in U.S. dollars) of all financial support provided.
20A.5
YES NO (If NO, proceed to 20B)
Country #1 Country #2
Provide this foreign national's country(ies) of citizenship.
Provide the name of the foreign national you support or have supported financially.
Provide the address of the foreign national listed above.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the nature of your relationship with the foreign national listed above.
Est.
Provide the frequency of your support.
Provide the amount (in U.S. dollars) of all financial support provided.
Country #1 Country #2
Provide this foreign national's country(ies) of citizenship.
Complete the following if you responded 'Yes' to providing financial support for any foreign national.
Section 20A - Foreign Activities - (Continued)
Have you EVER provided financial support for any foreign national?
Entry #1
Entry #2
Page 73
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Last name
First name
Middle name
Suffix
Provide the name of the individual to whom advice or support was provided.
Provide the name of the foreign organization or foreign business with whom the individual is
associated.
Provide the country of origin for the organization or business.
Provide a description of advice/support provided.
Provide the date(s) during which this advice or support was provided.
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Describe what compensation, if any, was provided for your service.
YES NO (If NO, proceed to 20B.2)
20B.1
Last name
First name
Middle name
Suffix
Provide the name of the individual to whom advice or support was provided.
Provide the name of the foreign organization or foreign business with whom the individual
is associated.
Provide the country of origin for the organization or business.
Provide a description of advice/support provided.
Provide the date(s) during which this advice or support was provided.
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Describe what compensation, if any, was provided for your service.
Entry #2
YES NO (If NO, proceed to 20B.3)
20B.2
(Month/Year)
Complete the following if you responded 'Yes' to you, your spouse or legally recognized civil union/domestic partner, cohabitant, or any member of your
immediate family having in the last seven (7) years been asked to provide advice or serve as a consultant, even informally, by any foreign government
official or agency.
Have you, your spouse or legally recognized civil union/domestic partner, cohabitant, or any member of
your immediate family in the last seven (7) years been asked to provide advice or serve as a consultant,
even informally, by any foreign government official or agency? (Answer 'No' if all the advice or support
was authorized pursuant to official U.S. Government business.)
Entry #1
Provide the name of the government official.
Suffix
Middle name
Last name
First name
Provide the name of the agency. Provide the country with which the government official or agency is affiliated.
Provide the circumstances of request.
Provide the date of the request.
Est.
For this question, 'Immediate Family' means your spouse or legally recognized civil union/domestic partner, parents, step-parents, siblings, half and step-
siblings, children, step-children, and cohabitant.
Entry #2
Provide the name of the government official.
Suffix
Middle name
Last name
First name
Provide the name of the agency. Provide the country with which the government official or agency is affiliated.
Provide the circumstances of request.
Provide the date of the request.
Est.
(Month/Year)
Complete the following if you responded 'Yes' to having in the last seven (7) years provided advice or support to any individual associated with a foreign
business or other foreign organization that you have not previously listed as a former employer.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts
Have you in the last seven (7) years provided advice or support to any individual associated with a
foreign business or other foreign organization that you have not previously listed as a former employer?
(Answer "No" if all your advice or support was authorized pursuant to official U.S. Government business.)
Entry #1
Page 74
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to 20B.4)
20B.3
Entry #2
Provide the name of the foreign national who made the offer.
Suffix
Middle name
Last name
First name
Provide a description of the position offered. Provide the date when this offer
was extended. (Month/Year)
Est.
YES
NO
Did you accept the offer?
Explanation
Provide location of where this occurred. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
State
Country
Zip Code
Complete the following if you responded 'Yes' to any foreign national having in the last seven (7) years offered you a job, asked you to work as a
consultant, or consider employment with them.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Has any foreign national in the last seven (7) years offered you a job, asked you to work as a
consultant, or consider employment with them?
Entry #1
Provide the name of the foreign national who made the offer.
Suffix
Middle name
Last name
First name
Provide a description of the position offered. Provide the date when this offer
was extended. (Month/Year)
Est.
YES
NO
Did you accept the offer?
Explanation
Provide location of where this occurred. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
State
Country
Zip Code
Explanation
Explanation
Page 75
Complete the following if you responded 'Yes' to having in the last seven (7) years been involved in any other type of business venture with a foreign
national not described above.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Have you in the last seven (7) years been involved in any other type of business venture with a foreign
national not described above (own, co-own, serve as business consultant, provide financial support, etc.)?
Entry #1
Provide the full name of this foreign national.
Provide the full current address of this foreign national.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the nature of association with
this business venture.
Provide a description of the business venture.
Provide your relationship to this foreign national.
Provide the length of time you have been involved in the business venture.
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Provide the service you provided.
Provide a description of what compensation was provided for your service.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Provide the position you held.
Provide the financial support involved.
Entry #2
Provide the full name of this foreign national.
Provide the full current address of this foreign national.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the nature of association with
this business venture.
Provide the length of time you have been involved in the business venture.
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Provide the service you provided.
Provide a description of what compensation was provided for your service.
Provide the position you held.
Provide the financial support involved.
YES NO (If NO, proceed to 20B.5)
20B.4
Country #1
Country #2
Provide the citizenship(s) of this foreign national.
Provide a description of the business venture.
Provide your relationship to this foreign national.
Country #1 Country #2
Provide the citizenship(s) of this foreign national.
Page 76
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to 20B.6)
20B.5
Entry #2
Provide the name and description of event.
Provide the country where the event was held.
Provide the purpose of the event.
Provide the name of sponsoring organization.
Provide the dates for the event.
From Date
Est.
To Date
Present
Est.
(Month/Year) (Month/Year)
Provide the city where the event was held.
NO
YES
Was there any subsequent contact with any foreign nationals as a result of the event?
Contact #1 explanation
Contact #2 explanation
Contact #3 explanation
Contact #4 explanation
Provide explanation
for each contact.
Complete the following if you responded 'Yes' to in the last seven (7) years having attended or participated in any conferences, trade shows, seminars,
or meetings outside the U.S.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Have you in the last seven (7) years attended or participated in any conferences, trade shows,
seminars, or meetings outside the U.S.? (Do not include those you attended or participated in on official
business for the U.S. government.)
Entry #1
Provide the name and description of event.
Provide the country where the event was held.
Provide the purpose of the event.
Provide the name of sponsoring organization.
Provide the dates for the event.
From Date
Est.
To Date
Present
Est.
(Month/Year) (Month/Year)
Provide the city where the event was held.
NO
YES
Was there any subsequent contact with any foreign nationals as a result of the event?
Contact #1 explanation
Contact #2 explanation
Contact #3 explanation
Contact #4 explanation
Provide explanation
for each contact.
Page 77
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES
NO (If NO, Proceed to
20B.7)
20B.6
Provide the type of establishment (such as
embassy, consulate, agency, military service,
intelligence or security service, etc.) involved.
Entry #2
Provide the purpose/circumstances of contact.
Provide the type of establishment (such as
embassy, consulate, agency, military service,
intelligence or security service, etc.) involved.
Provide the name of the individual involved in the contact.
Provide the location of the contact.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
NO
YES
Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign organization?
Provide the purpose of the subsequent contact
Provide date of most recent
contact (Month/Day/Year)
Provide plans for future contact
For this question, 'Immediate Family' means your spouse, parents, step-parents, siblings, half and step- siblings, children, step-children, and cohabitant.
Complete the following if you responded 'Yes' to you or any member of your immediate family having in the last seven (7) years had any contact with a
foreign government, its establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) or its representatives,
whether inside or outside the U.S.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Have you or any member of your immediate family in the last seven (7) years had any contact with a foreign
government, its establishment (such as embassy, consulate, agency, military service, intelligence or security
service, etc.) or its representatives, whether inside or outside the U.S.? (Answer 'No' if the contact was for
routine visa applications and border crossings related to either official U.S. Government travel, foreign travel
on a U.S. passport, or as a U.S. military service member in conjunction with a U.S. Government military duty.)
Entry #1
Provide the name of the individual involved in the contact.
Provide the location of the contact.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the date of contact.
(Month/Year)
Est.
NO
YES
Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign organization?
Provide the purpose of the subsequent contact
Provide date of most recent
contact (Month/Day/Year)
Provide plans for future contact
Country #1 Country #2
Provide the foreign government(s) involved.
Provide the date of contact.
(Month/Year)
Est.
Country #1
Country #2
Provide the foreign government(s) involved.
Provide the names of the foreign
representatives involved in contact.
Provide the names of the foreign
representatives involved in contact.
Provide the purpose/circumstances of contact.
Page 78
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES
NO (If NO, proceed to 20B.8)
20B.7
Complete the following if you responded 'Yes' to in the last seven (7) years having sponsored any foreign national to come to the U.S. as a student, for
work, or for permanent residence.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Have you in the last seven (7) years sponsored any foreign national to come to the U.S. as a student,
for work, or for permanent residence?
Entry #1
Provide the name of the sponsored foreign national.
Provide the date of birth for the sponsored foreign national.
City
State
Country
(Required)
Provide the place of birth for the sponsored foreign national.
Zip Code
Date (Month/Year)
Est.
Suffix
Middle name
Last name
First name
Provide the dates of stay in the U.S. for the sponsored foreign national.
From Date (Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Provide the purpose of stay in the U.S. for the sponsored foreign national.
Provide the purpose of your sponsorship for the sponsored foreign national.
I don't know
Provide the current street address of the sponsored foreign national. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the address of the organization through which sponsorship was arranged, if applicable. (Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Not Applicable
Provide the address of the sponsored foreign national while residing in the U.S.
Street
City
State
Zip Code
Not Applicable
Country #1 Country #2
Provide the country(ies) of citizenship for the sponsored foreign national.
Provide the name of the organization through
which sponsorship was arranged, if applicable.
Page 79
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Complete the following if you responded 'Yes' to in the last seven (7) years having sponsored any foreign national to come to the U.S. as a student, for
work, or for permanent residence.
Entry #2
Provide the name of the sponsored foreign national.
Provide the date of birth for the sponsored foreign national.
City
State
Country
(Required)
Provide the place of birth for the sponsored foreign national.
Zip Code
Date (Month/Year)
Est.
Suffix
Middle name
Last name
First name
Provide the dates of stay in the U.S. for the sponsored foreign national.
From Date (Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Provide the purpose of stay in the U.S. for the sponsored foreign national.
Provide the purpose of your sponsorship for the sponsored foreign national.
I don't know
Provide the current street address of the sponsored foreign national. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the address of the organization through which sponsorship was arranged, if applicable. (Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Not Applicable
Provide the address of the sponsored foreign national while residing in the U.S.
Street
City
State
Zip Code
Not Applicable
Country #1 Country #2
Provide the country(ies) of citizenship for the sponsored foreign national.
Provide the name of the organization through
which sponsorship was arranged, if applicable.
Page 80
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Complete the following if you responded 'Yes' to having EVER voted in the election of a foreign country.
YES NO (If NO, Proceed to 20C)
Have you EVER voted in the election of a foreign country?
Entry #1
Provide your current eligibility to vote in a foreign country.
Provide the date you voted in the foreign election. (Month/Year)
Est.
Provide the reason(s) for these activities.
Provide the name of the country involved.
YES NO (If NO, proceed to 20B.9)
20B.8
Entry #2
Entry #2
Provide your current eligibility to vote in a foreign country.
Provide the date you voted in the foreign election. (Month/Year)
Est.
Provide the reason(s) for these activities.
Provide the name of the country involved.
20B.9
Provide the position held.
Provide your current eligibility to hold political office in a foreign country.
Provide the name of the country involved.
Provide the reason(s) for these activities.
Provide the dates you held political office.
Est.
To Date (Month/Year)
Present
Est.
From Date
(Month/Year)
Complete the following if you responded 'Yes' to having EVER held political office in a foreign country.
Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)
Have you EVER held political office in a foreign country?
Entry #1
Provide the position held.
Provide your current eligibility to hold political office in a foreign country.
Provide the name of the country involved.
Provide the reason(s) for these activities.
Provide the dates you held political office.
Est.
To Date (Month/Year)
Present
Est.
From Date
(Month/Year)
Page 81
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
NO (If NO, proceed to Section 21)YES
YES (If YES, proceed to Section 21) NO
Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business.
Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business
on official government orders.
Section 20C - Foreign Travel
Have you traveled outside the U.S. in the last seven (7) years?
Entry #1
Has your travel in the last seven (7) years been solely for U.S. Government business/military overseas
assignment on official government orders (i.e., no personal trips in conjunction with the official U.S.
Government business)?
Provide the dates of your travel to this country.
From Date
Est.
To Date
Present
Est.
(Month/Year) (Month/Year)
If yes, provide explanation.
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you involved in any encounter with the police?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive
information?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign
intelligence or security service?
Provide the country visited.
Provide the total number of days involved in the visit.
1-5
6-10
11-20
21-30
More than 30
Many short trips
Visit family or friends
Trade shows, conferences, and seminarsEducation
TourismVolunteer activities
Business/Professional conference
Provide the purpose of the travel to this country (Check all that apply).
Other
NO
YES
Page 82
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20C - Foreign Travel - (Continued)
Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business.
Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business
on official government orders.
Entry #2
Provide the dates of your travel to this country.
From Date
Est.
To Date
Present
Est.
(Month/Year) (Month/Year)
If yes, provide explanation.
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you involved in any encounter with the police?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive
information?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign
intelligence or security service?
Provide the country visited.
Provide the total number of days involved in the visit.
1-5
6-10
11-20
21-30
More than 30
Many short trips
Visit family or friends
Trade shows, conferences, and seminarsEducation
TourismVolunteer activities
Business/Professional conference
Provide the purpose of the travel to this country (Check all that apply).
Other
NO
YES
Page 83
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20C - Foreign Travel - (Continued)
Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business.
Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business
on official government orders.
Entry #3
Provide the dates of your travel to this country.
From Date
Est.
To Date
Present
Est.
(Month/Year) (Month/Year)
If yes, provide explanation.
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you involved in any encounter with the police?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive
information?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign
intelligence or security service?
Provide the country visited.
Provide the total number of days involved in the visit.
1-5
6-10
11-20
21-30
More than 30
Many short trips
Visit family or friends
Trade shows, conferences, and seminarsEducation
TourismVolunteer activities
Business/Professional conference
Provide the purpose of the travel to this country (Check all that apply).
Other
NO
YES
Page 84
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 20C - Foreign Travel - (Continued)
Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business.
Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business
on official government orders.
Entry #4
Provide the dates of your travel to this country.
From Date
Est.
To Date
Present
Est.
(Month/Year) (Month/Year)
If yes, provide explanation.
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local
customs or security service officials when entering or leaving this country?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you involved in any encounter with the police?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign
intelligence, terrorist, security, or military organizations?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?
If yes, provide explanation.
NO
YES
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive
information?
If yes, provide explanation.
NO
YES
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign
intelligence or security service?
Provide the country visited.
Provide the total number of days involved in the visit.
1-5
6-10
11-20
21-30
More than 30
Many short trips
Visit family or friends
Trade shows, conferences, and seminarsEducation
TourismVolunteer activities
Business/Professional conference
Provide the purpose of the travel to this country (Check all that apply).
Other
NO
YES
Page 85
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 21B)
Section 21 - Psychological and Emotional Health
21A
The U.S. government recognizes the critical importance of mental health and advocates proactive management of mental health conditions to support the
wellness and recovery of Federal employees and others. Every day individuals with mental health conditions carry out their duties without presenting a
security risk. While most individuals with mental health conditions do not present security risks, there may be times when such a condition can affect a
person’s eligibility for a security clearance.
Individuals experience a range of reactions to traumatic events. For example, the death of a loved one, divorce, major injury, service in a military combat
environment, sexual assault, domestic violence, or other difficult work-related, family, personal, or medical issues may lead to grief, depression, or other
responses. The government recognizes that mental health counseling and treatment may provide important support for those who have experienced such
events, as well as for those with other mental health conditions. Nothing in this questionnaire is intended to discourage those who might benefit from such
treatment from seeking it.
Mental health treatment and counseling, in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a
sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for physical or logical access to federally controlled
facilities or information systems. Seeking or receiving mental health care for personal wellness and recovery may contribute favorably to decisions about
your eligibility.
Has a court or administrative agency EVER issued an order declaring you mentally incompetent?
(Month/Year)
YES NO
Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Provide the date this occurred.
Est.
Provide the name of the court or administrative agency that declared you mentally incompetent.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Was this matter appealed to a higher court or administrative agency?
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Appeal #1
Appeal #2
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Entry #1
Page 86
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 21A - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'Yes' to having a court or administrative agency EVER issuing an order declaring you mentally incompetent.
Entry #2
Entry #3
(Month/Year)
YES NO
Provide the date this occurred.
Est.
Provide the name of the court or administrative agency that declared you mentally incompetent.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Was this matter appealed to a higher court or administrative agency?
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Appeal #1
Appeal #2
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
(Month/Year)
YES NO
Provide the date this occurred.
Est.
Provide the name of the court or administrative agency that declared you mentally incompetent.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Was this matter appealed to a higher court or administrative agency?
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Appeal #1
Appeal #2
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Page 87
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 21C)
Section 21B - Psychological and Emotional Health - (Continued)
21B Has a court or administrative agency EVER ordered you to consult with a mental health
professional (for example, a psychiatrist, psychologist, licensed clinical social worker, etc.)?
(An order to a military member by a superior officer is not within the scope of this question,
and therefore would not require an affirmative response. An order by a military court would be
within the scope of the question and would require an affirmative response.)
YES NO
Complete the following if you responded 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.
Provide the date this occurred.
(Month/Year)
Est.
Provide the name of the court or administrative agency that ordered you to consult with a mental
health professional.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Was this matter appealed to a higher court or administrative agency?
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Appeal #1
Appeal #2
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Entry #1
Provide the final disposition.
Page 88
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 21B - Psychological and Emotional Health - (Continued)
YES NO
Complete the following if you responded 'Yes' to having a court or administrative agency EVER ordered you to consult with a mental health professional.
Provide the date this occurred.
(Month/Year)
Est.
Provide the name of the court or administrative agency that ordered you to consult with a mental
health professional.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Was this matter appealed to a higher court or administrative agency?
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Appeal #1
Appeal #2
Provide the name of the court or administrative agency.
Provide the address of the court or administrative agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the final disposition.
Entry #2
Provide the final disposition.
Page 89
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 21D)
Section 21C - Psychological and Emotional Health - (Continued)
21C Have you EVER been hospitalized for a mental health condition?
Complete the following if you responded 'Yes' to having EVER been hospitalized for a mental health condition
Entry #1
Provide the dates of treatment.
Provide the name of the facility where treatment was provided.
Provide the address of the facility where treatment was provided.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
From Date
(Month/Year)
Est.
To Date
(Month/Year)
Present
Est.
Voluntary
Was the admission voluntary or involuntary?
Involuntary
Explanation
Explanation
Entry #2
Provide the dates of treatment.
Provide the name of the facility where treatment was provided.
Provide the address of the facility where treatment was provided.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
From Date
(Month/Year)
Est.
To Date
(Month/Year)
Present
Est.
Voluntary
Was the admission voluntary or involuntary?
Involuntary
Explanation
Explanation
Entry #3
Provide the dates of treatment.
Provide the name of the facility where treatment was provided.
Provide the address of the facility where treatment was provided.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
From Date
(Month/Year)
Est.
To Date
(Month/Year)
Present
Est.
Voluntary
Was the admission voluntary or involuntary?
Involuntary
Explanation
Explanation
Entry #4
Provide the dates of treatment.
Provide the name of the facility where treatment was provided.
Provide the address of the facility where treatment was provided.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
From Date
(Month/Year)
Est.
To Date
(Month/Year)
Present
Est.
Voluntary
Was the admission voluntary or involuntary?
Involuntary
Explanation
Explanation
Page 90
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 21E)
Section 21D - Psychological and Emotional Health - (Continued)
21D Have you EVER been diagnosed by a physician or other health professional (for example, a
psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner) with psychotic
disorder, schizophrenia, schizoaffective disorder, delusional disorder, bipolar mood disorder,
borderline personality disorder, or antisocial personality disorder?
Complete the following if you responded 'Yes' to having EVER been diagnosed by a physician or other health professional.
Entry #1
The following question asks whether you have been diagnosed with a specified mental health condition that may, particularly if untreated, impact your
judgment, reliability, or trustworthiness. If you answer in the affirmative, we will seek additional information about the seriousness and symptoms of the
condition, as well as any applicable course of treatment. It is important to note that any such diagnosis, in and of itself, is not a reason to revoke or deny
eligibility for access to classified information or for holding a sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or
eligibility for physical or logical access to federally controlled facilities or information systems.
Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
Provide the address of agency/organization/facility where counseling/treatment was provided.
(Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
NO YES
Was the counseling/treatment effective in managing your symptoms?
If no, provide explanation
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Entry #2
Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
Provide the address of agency/organization/facility where counseling/treatment was provided.
(Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
NO YES
Was the counseling/treatment effective in managing your symptoms?
If no, provide explanation
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.
Provide the dates of diagnosis.
From Date(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN
phone number
Provide the telephone number of the health care professional.
Identify the diagnosis or health condition.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.
Provide the dates of diagnosis.
From Date(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN
phone number
Provide the telephone number of the health care professional.
Identify the diagnosis or health condition.
Page 91
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 21D - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'Yes' to having EVER been diagnosed by a physician or other health professional.
Entry #3
Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
Provide the address of agency/organization/facility where counseling/treatment was provided.
(Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
NO YES
Was the counseling/treatment effective in managing your symptoms?
If no, provide explanation
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Entry #4
Provide the address of the health care professional who diagnosed you, or is currently treating you for such diagnosis, or with whom you have discussed
such condition. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
Provide the address of agency/organization/facility where counseling/treatment was provided.
(Provide City and Country if outside the
United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
NO YES
Was the counseling/treatment effective in managing your symptoms?
If no, provide explanation
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.
Provide the dates of diagnosis.
From Date(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN
phone number
Provide the telephone number of the health care professional.
Identify the diagnosis or health condition.
Provide the name of the health care professional who diagnosed you, or is currently
treating you for such diagnosis, or with whom you have discussed such condition.
Provide the dates of diagnosis.
From Date(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN
phone number
Provide the telephone number of the health care professional.
Identify the diagnosis or health condition.
Page 92
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 21E)
Section 21D - Psychological and Emotional Health - (Continued)
21D.1 Are you currently in treatment?
Complete the following if you responded 'Yes' to currently being in treatment.
Entry #1
Provide the name of the health care professional providing
such treatment.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
Entry #2
Provide the name of the health care professional providing
such treatment.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
Entry #3
Provide the name of the health care professional providing
such treatment.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
Entry #4
Provide the name of the health care professional providing
such treatment.
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
NO YES
In the last seven years, have there been any occasions when you did not consult with a medical professional before
altering or discontinuing, or failing to start a prescribed course of treatment for any of the listed diagnoses?
Page 93
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO
Section 21E - Psychological and Emotional Health - (Continued)
21E Do you have a mental health or other health condition that substantially adversely affects your judgment, reliability, or
trustworthiness even if you are not experiencing such symptoms today?
Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.
Entry #1
Provide the name of the health care professional.
Provide the dates of counseling or treatment
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside
the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
NO
YES I decline to answer (If I decline to answer, proceed to Section 22)
Did you ever receive or are you currently receiving counseling or treatment for that condition? (You may choose not to answer this question. However, such
consultation or treatment will not disqualify you and is considered to be a positive action.)
(If NO, provide explanation and proceed to Section 22).
If you responded 'Yes' to having ever received or you are currently receiving counseling or treatment for that condition.
#1
Same as
above
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Provide the name of the health care professional.
Provide the dates of counseling or treatment
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside
the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
#2
Same as
above
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Complete the following if you responded ‘No’ to 21A, 21B, 21C, and 21D (All). If ‘Yes’ was selected for either 21A, 21B, 21C, or 21D, proceed to Section 22.
NO
YES
Have you ever chosen not to follow a prescribed course of treatment for any of these conditions?
If YES, provide explanation
(Note: If your judgment, reliability, or trustworthiness is not substantially adversely affected by a mental health or other condition, then you should
answer "no" even if you have a mental health or other condition requiring treatment. For example, if you are in need of emotional or mental health
counseling as a result of service as a first responder, service in a military combat environment, having been sexually assaulted or a victim of domestic
violence, or marital issues, but your judgment, reliability or trustworthiness is not substantially adversely affected, then answer "no.")
Page 94
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 21E - Psychological and Emotional Health - (Continued)
Complete the following if you responded 'Yes' to having a mental health condition that adversely affects your judgment, reliability, or trustworthiness.
Entry #2
Provide the name of the health care professional.
Provide the dates of counseling or treatment
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside
the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
If you responded 'Yes' to having ever received or you are currently receiving counseling or treatment for that condition.
#1
Same as
above
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
Provide the name of the health care professional.
Provide the dates of counseling or treatment
Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the address of agency/organization/facility where counseling/treatment was provided. (Provide City and Country if outside
the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as
above
From Date
(Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the health care professional.
#2
Same as
above
Same as
above
Provide the name of any agency/organization/facility
where counseling/treatment was provided
Day Night
Telephone number
Extension
International or DSN phone number
Provide the telephone number of the agency/organization/facility.
NO
YES
Have you ever chosen not to follow a prescribed course of treatment for any of these conditions?
If YES, provide explanation
Page 95
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
22.1
YES NO (If NO, proceed to 22.2)
YES NO (If NO, proceed to (c))
(a)
(b)
(c)
- In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?
(Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)
- In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
- In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
- In the last seven (7) years have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?
Provide the name of the court.
(If YES, complete (c.1))
Entry #1
Section 22 - Police Record
Have any of the following happened? (If 'Yes' you will be asked to provide details for each offense that
pertains to the actions that are identified below.)
Entry #1
Provide the date of offense. (Month/Year)
Est.
Provide a description of the specific nature of the offense.
For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or
the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order
under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.
Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City
State
Country
Zip Code
Did this offense involve any of the following?
YES NO
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other
type of law enforcement official?
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City
State
Country
Zip Code
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?
YES
NO
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City
State
Country
Zip Code
Provide explanation
Felony/misdemeanor Charge Outcome Date (Month/Year)
Est.
Est.
Est.
Est.
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge
dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser
offense.
County
County
County
(c.1)
(Check all that apply.)
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 legally recognized civil union/domestic partner, or someone with whom you share
a child in common?
Involve firearms or explosives?
Involve alcohol or drugs?
Page 96
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
(d)
YES (If YES, complete (d.1)) NO (If NO, complete (d.2))
(d.1)
(Month/Year) (Month/Year)
If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.
To Date
Present
Est.
Not Applicable
(Month/Year) (Month/Year)
(d.2)
Entry #1
Complete the following if you responded 'Yes' to one of the following:
- In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?
(Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)
- In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
- In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
- In the last seven (7) years have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?
Section 22 - Police Record - (Continued)
Were you sentenced as a result of this offense?
Provide a description of the sentence.
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Were you incarcerated as a result of that sentence for not less than 1 year?
NOYES
From Date
Est.
If conviction resulted in probation or parole, provide the dates of
probation or parole.
From Date
Est.
To Date
Present
Est.
Not Applicable
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES NO
Provide explanation.
Page 97
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Complete the following if you responded 'Yes' to one of the following:
- In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?
(Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)
- In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
- In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
- In the last seven (7) years have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?
Section 22 - Police Record - (Continued)
YES NO (If NO, proceed to (c))
(a)
(b)
(c)
Provide the name of the court.
(If YES, complete (c.1))
Entry #2
Entry #2
Provide the date of offense. (Month/Year)
Est.
Provide a description of the specific nature of the offense.
Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City
State
Country
Zip Code
Did this offense involve any of the following?
YES NO
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other
type of law enforcement official?
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City
State
Country
Zip Code
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?
YES
NO
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
City
State
Country
Zip Code
Provide explanation
Felony/misdemeanor Charge Outcome Date (Month/Year)
Est.
Est.
Est.
Est.
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge
dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser
offense.
County
County
County
(c.1)
(Check all that apply.)
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 legally recognized civil union/domestic partner, or someone with whom you share
a child in common?
Involve firearms or explosives?
Involve alcohol or drugs?
Page 98
Entry #2
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
(d)
YES (If YES, complete (d.1)) NO (If NO, complete (d.2))
(d.1)
(Month/Year) (Month/Year)
(Month/Year) (Month/Year)
(d.2)
Complete the following if you responded 'Yes' to one of the following:
- In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?
(Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)
- In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
- In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges,
convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
- In the last seven (7) years have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?
Section 22 - Police Record - (Continued)
Were you sentenced as a result of this offense?
Provide a description of the sentence.
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Were you incarcerated as a result of that sentence for not less than 1 year?
NOYES
If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.
From Date
Est.
To Date
Present
Est.
If conviction resulted in probation or parole, provide the dates of
probation or parole.
From Date
Est.
To Date
Present
Est.
Not Applicable
Not Applicable
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES NO
Provide explanation.
Page 99
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
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 legally recognized civil union/domestic partner, or someone with whom you share a child in common?
Involve firearms or explosives?
Involve alcohol or drugs?
YES NO (If NO, proceed to 22.3)
22.2
(a)
(b)
YES NO
(b.1)
- Have you EVER been convicted in any court of the United States of a crime, sentenced to imprisonment for a term exceeding 1 year for
that crime, and incarcerated as a result of that sentence for not less than 1 year? (Include all qualifying convictions in Federal, state,
local, or military court, even if previously listed on this form)
- Have you EVER been charged with any felony offense? (Include those under the Uniform Code of Military Justice and non-military/
civilian felony offenses)
- 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 legally recognized civil union/
domestic partner, or someone with whom you share a child in common?
- Have you EVER been charged with an offense involving firearms or explosives?
- Have you EVER been charged with an offense involving alcohol or drugs?
(Month/Year)
(Month/Year)
(Month/Year)
(Month/Year)
Felony/misdemeanor Charge Outcome Date (Month/Year)
Est.
Est.
Est.
Est.
(Check all that apply).
Section 22 - Police Record - (Continued)
Other than those offenses already listed, have you EVER had the following happen to you?
Entry #1
Provide the date of offense. (Month/Year)
Est.
Provide a description of the specific nature of the offense.
Did this offense involve any of the following?
Provide the name of the court.
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Provide all the 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 pleaded guilty to a lesser offense, list both the original charge and the lesser
offense separately.
Were you sentenced as a result of these charges?
YES (If YES, complete (b.1)) NO (If NO, complete (b.2))
Provide a description of the sentence.
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Were you incarcerated as a result of that sentence for not less than 1 year?
YES NO
If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.
From Date
Est.
To Date
Present
Est.
If conviction resulted in probation or parole, provide the dates of
probation or parole.
From Date
Est.
To Date
Present
Est.
Not Applicable
Not Applicable
(b.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES NO
Provide explanation.
City
State
Country
Zip Code
County
Page 100
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 22 - Police Record - (Continued)
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 legally recognized civil union/domestic partner, or someone with whom you share a child in common?
Involve firearms or explosives?
Involve alcohol or drugs?
(a)
(b)
YES NO
(b.1)
(Month/Year)
(Month/Year)
(Month/Year)
(Month/Year)
Felony/misdemeanor Charge Outcome Date (Month/Year)
Est.
Est.
Est.
Est.
(Check all that apply).
Entry #2
Provide the date of offense. (Month/Year)
Est.
Provide a description of the specific nature of the offense.
Did this offense involve any of the following?
Provide the name of the court.
Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)
Provide all the 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 pleaded guilty to a lesser offense, list both the original charge and the lesser
offense separately.
Were you sentenced as a result of these charges?
YES (If YES, complete (b.1)) NO (If NO, complete (b.2))
Provide a description of the sentence.
Were you sentenced to imprisonment for a term exceeding 1 year?
YES NO
Were you incarcerated as a result of that sentence for not less than 1 year?
YES NO
If the conviction resulted in imprisonment, provide the dates that you
actually were incarcerated.
From Date
Est.
To Date
Present
Est.
If conviction resulted in probation or parole, provide the dates of
probation or parole.
From Date
Est.
To Date
Present
Est.
Not Applicable
Not Applicable
(b.2)
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?
YES NO
Provide explanation.
City
State
Country
Zip Code
County
Page 101
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO (If NO, proceed to Section 23)
22.3
Section 22 - Police Record - (Continued)
Is there currently a domestic violence protective order or restraining order issued against you?
Entry #1
Provide the date the order was issued. (Month/Year)
Est.
Provide explanation.
Provide the name of the court or agency that issued the order.
Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
State
Country
Zip Code
Complete the following if you responded 'Yes' to currently having a domestic violence protective order or restraining order issued against you?
Entry #2
Provide the date the order was issued. (Month/Year)
Est.
Provide explanation.
Provide the name of the court or agency that issued the order.
Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
State
Country
Zip Code
Entry #3
Provide the date the order was issued. (Month/Year)
Est.
Provide explanation.
Provide the name of the court or agency that issued the order.
Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
State
Country
Zip Code
Entry #4
Provide the date the order was issued. (Month/Year)
Est.
Provide explanation.
Provide the name of the court or agency that issued the order.
Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
City
State
Country
Zip Code
Page 102
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES NO
23.1
YES NO
Entry #2
Provide the type of drug or controlled substance.
(Provide explanation)
Provide an estimate of the month
and year of first use. (Month/Year)
Est.
Provide an estimate of the month and
year of most recent use. (Month/Year)
Est.
Provide nature of use, frequency, and number of times used.
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 the public safety?
Was your use while possessing a security clearance?
YES NO
Do you intend to use this drug or controlled substance in the future?
YES NO
Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Section 23 - Illegal Use of Drugs and Drug Activity
We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as
evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal
government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity in accordance with
Federal laws, even though permissible under state laws.
YES NO (If NO, proceed to 23.2)
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.
Complete the following if you answered 'Yes' to in the last seven (7) years having illegally used a drug or controlled substance.
Entry #1
Provide the type of drug or controlled substance.
Provide an estimate of the month
and year of first use. (Month/Year)
Est.
Provide an estimate of the month and
year of most recent use. (Month/Year)
Est.
Provide nature of use, frequency, and number of times used.
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 the public safety?
Was your use while possessing a security clearance?
YES NO
Do you intend to use this drug or controlled substance in the future?
YES NO
Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, 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)
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.) Other
Page 103
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
23.2
(Provide explanation)
Provide the nature and frequency of activity.Provide an estimate of the month and
year of first involvement. (Month/Year)
Est.
Provide an estimate of the month and year
of most recent involvement. (Month/Year)
Est.
Provide explanation.
(Provide explanation)
Provide explanation.
Entry #2
Provide the type of drug or controlled substance.
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
Was your involvement while possessing a security clearance?
NOYES
Do you intend to engage in this activity in the future?
NO
YES
Provide the reason(s) why you engaged in the activity.
Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)
YES NO (If NO, proceed to 23.3)
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?
Complete the following if you answered 'Yes' to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation,
trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance.
Entry #1
Provide the type of drug or controlled substance.
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
Was your involvement while possessing a security clearance?
YES NO
Do you intend to engage in this activity in the future?
YES
NO
Provide the reason(s) why you engaged in the activity.
Provide the nature and frequency of activity.Provide an estimate of the month and
year of first involvement. (Month/Year)
Est.
Provide an estimate of the month and year
of most recent involvement. (Month/Year)
Est.
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.) Other
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.) Other
Page 104
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
23.3
Present
(Month/Year) (Month/Year)
Present
(Month/Year) (Month/Year)
Entry #2
From Date
Est.
To Date
Est.
Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this
drug or controlled substance while possessing a security clearance.
Provide a description of your involvement.
Present
(Month/Year) (Month/Year)
From Date
Est.
To Date
Est.
Present
(Month/Year) (Month/Year)
From Date
Est.
To Date
Est.
Entry #2
Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this
drug or controlled substance while employed in this capacity.
Provide a description of the drugs or controlled substances used and your involvement.
23.4
YES NO (If NO, proceed to 23.5)
Have you EVER 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?
Complete the following if you responded 'Yes' to having EVER 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.
Entry #1
Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this
drug or controlled substance while employed in this capacity.
Provide a description of the drugs or controlled substances used and your involvement.
Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)
YES NO (If NO, proceed to 23.4)
Have you EVER illegally used or otherwise been illegally involved with a drug or controlled substance
while possessing a security clearance other than previously listed?
Complete the following if you responded 'Yes' to having EVER illegally used or otherwise been illegally involved with a drug or controlled substance while
possessing a security clearance other than previously listed.
Entry #1
From Date
Est.
To Date
Est.
Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this
drug or controlled substance while possessing a security clearance.
Provide a description of your involvement.
Page 105
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
23.5
Present
(Month/Year) (Month/Year)
From Date
Est.
To Date
Est.
Present
(Month/Year) (Month/Year)
From Date
Est.
To Date
Est.
Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)
YES
NO (If NO, proceed to 23.6)
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?
Complete the following if you responded 'Yes' to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless
of whether the drugs were prescribed for you or someone else.
Entry #1
Provide the dates of involvement in the above. Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Provide the name of the prescription drug that you misused.
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
Was your involvement while possessing a security clearance?
NOYES
Entry #2
Provide the dates of involvement in the above. Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Provide the name of the prescription drug that you misused.
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
Was your involvement while possessing a security clearance?
NOYES
Page 106
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
23.6
(Month/Year) (Month/Year)
Present
From Date
Est.
To Date
Est.
Provide the dates of treatment.
Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)
YES NO (If NO, proceed to 23.7)
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your
illegal use of drugs or controlled substances?
Complete the following if you responded 'Yes' to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your
illegal use of drugs or controlled substances.
Entry #1
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?
(Check all that apply):
An employer, military commander, or employee assistance program
A medical professional
A mental health professional
A court official / judge
I have not been ordered, advised, or asked to seek
counseling or treatment by any of the above.
Provide explanation
Did you take action to receive counseling or treatment?
NO (If NO, complete (a))YES (If YES, complete (b))
Provide explanation.
(a) You have indicated that you did not receive treatment.
(b) You have indicated that you did receive treatment.
Provide the address for this treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Last name
First name
Provide a telephone number for the
treatment provider.
Extension
International or DSN
phone number
Day Night
Provide the name of the treatment provider.
Did you successfully complete the treatment?
YES NO
(Provide explanation)
(Provide explanation)
Provide the type of drug or controlled substance for which you were treated.
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.) Other
Page 107
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
(Month/Year) (Month/Year)
Present
From Date
Est.
To Date
Est.
Provide the dates of treatment.
Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)
Complete the following if you responded 'Yes' to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your
illegal use of drugs or controlled substances.
Entry #2
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?
(Check all that apply):
An employer, military commander, or employee assistance program
A medical professional
A mental health professional
A court official / judge
I have not been ordered, advised, or asked to seek
counseling or treatment by any of the above.
Provide explanation
Did you take action to receive counseling or treatment?
NO (If NO, complete (a))YES (If YES, complete (b))
Provide explanation.
(a) You have indicated that you did not receive treatment.
(b) You have indicated that you did receive treatment.
Provide the address for this treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Last name
First name
Provide a telephone number for the
treatment provider.
Extension
International or DSN
phone number
Day Night
Provide the name of the treatment provider.
Did you successfully complete the treatment?
YES NO
(Provide explanation)
(Provide explanation)
Provide the type of drug or controlled substance for which you were treated.
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)
Inhalants (Such as toluene, amyl nitrate, etc.) Other
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.)
Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, 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)
23.7
Cocaine or crack cocaine (Such as rock, freebase, etc.)
THC (Such as marijuana, weed, pot, hashish, etc.)
Ketamine (Such as special K, jet, etc.)
Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
Depressants (Such as barbiturates, methaqualone, tranquilizers, 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)
Entry #2
Provide the type of drug or controlled substance for which you were treated.
Provide the address for this treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
(Month/Year) (Month/Year)
Present
From Date
Est.
To Date
Est.
Provide the dates of treatment.
Provide a telephone number for the
treatment provider.
Extension
International or DSN phone
number
Day Night
Last name
First name
Provide the name of the treatment provider.
Did you successfully complete the treatment?
YES NO
(Provide explanation)
Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)
YES NO (If NO, proceed to Section 24)
Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or
controlled substance?
Complete the following if you responded 'Yes' to having EVER voluntarily sought counseling or treatment as a result of your use of a drug or
controlled substance?
Entry #1
Provide the type of drug or controlled substance for which you were treated.
Provide the address for this treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
(Month/Year) (Month/Year)
Present
From Date
Est.
To Date
Est.
Provide the dates of treatment.
Provide a telephone number for the
treatment provider.
Extension
International or DSN
phone number
Day Night
Last name
First name
Provide the name of the treatment provider.
Did you successfully complete the treatment?
YES NO
(Provide explanation)
Page 108
Enter your Social Security Number before going to the next page
Page 109
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
24.1
Section 24 - Use of Alcohol
YES NO (If NO, proceed to 24.2)
In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your
professional or personal relationships, your finances, or resulted in intervention by law enforcement/public
safety personnel?
Complete the following if you responded 'Yes' to your alcohol use having had a negative impact on your work performance, your professional or personal
relationships, your finances, or resulted in intervention by law enforcement/public safety personnel.
Entry #1
Provide the month/year when this negative impact occurred.
From Date
(Month/Year)
Est.
Provide circumstances. Provide negative impact.
Provide dates of involvement or use.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #2
Provide the month/year when this negative impact occurred.
From Date
(Month/Year)
Est.
Provide circumstances. Provide negative impact.
Provide dates of involvement or use.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #3
Provide the month/year when this negative impact occurred.
From Date
(Month/Year)
Est.
Provide circumstances. Provide negative impact.
Provide dates of involvement or use.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #4
Provide the month/year when this negative impact occurred.
From Date
(Month/Year)
Est.
Provide circumstances. Provide negative impact.
Provide dates of involvement or use.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Page 110
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
An employer, military commander, or employee assistance program
A medical professional
A mental health professional
A court official / judge
I have not been ordered, advised, or asked to seek
counseling or treatment by any of the above.
Other
International or DSN phone number
Day Night
Section 24 - Use of Alcohol - (Continued)
YES NO (If NO, proceed to 24.3)
Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your use of
alcohol?
Complete the following if you responded 'Yes' to having been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol.
Entry #1
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check all that apply)
Extension
Provide telephone number.
(Provide explanation)
Did you take action to receive counseling or treatment?
NO (If NO, complete (a))YES (If YES, complete (b))
Provide explanation.
(a) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.
(b) You responded 'Yes' to having taken action to seek counseling or treatment.
Provide the full address for the counseling/treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the name of the individual counselor or treatment provider.
Did you successfully complete the treatment program?
YES NO
(Provide explanation)
24.2
Provide the dates of counseling or treatment.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
An employer, military commander, or employee assistance program
A medical professional
A mental health professional
A court official / judge
I have not been ordered, advised, or asked to seek
counseling or treatment by any of the above.
Other
Entry #2
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check all that apply):
(Provide explanation)
Enter your Social Security Number before going to the next page
International or DSN phone number
Day Night
Extension
Provide telephone number.
Did you take action to receive counseling or treatment?
NO (If NO, complete (a))YES (If YES, complete (b))
Provide explanation.
(a) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.
(b) You responded 'Yes' to having taken action to seek counseling or treatment.
Provide the full address for the counseling/treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the name of the individual counselor or treatment provider.
Did you successfully complete the treatment program?
YES NO
(Provide explanation)
Provide the dates of counseling or treatment.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Page 111
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
24.3
Entry #2
Provide the full address of the counseling/treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Provide the name of the individual counselor or treatment provider.
Provide the dates of counseling or treatment.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Did you successfully complete the treatment program?
YES NO
(Provide explanation)
Section 24 - Use of Alcohol - (Continued)
YES NO (If NO, proceed to 24.4)
Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment.
Entry #1
Provide the full address of the counseling/treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Provide the name of the individual counselor or treatment provider.
Provide the dates of counseling or treatment.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Did you successfully complete the treatment program?
YES NO
(Provide explanation)
Page 112
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
24.4
Did you successfully complete your counseling or treatment?
YES (Provide explanation) NO (Provide explanation)
Explanation
Did you successfully complete your counseling or treatment?
YES (Provide explanation) NO (Provide explanation)
Explanation
Entry #2
Provide the full address of the counseling/treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Name
Provide the name of individual counselor or treatment provider.
Provide the address of agency/organization where counseling/treatment was provided. (
Provide City and Country if outside the United States;
otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as above
Provide the dates of counseling or treatment.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Name
Provide the name of agency/organization where counseling/treatment was provided.
Section 24 - Use of Alcohol - (Continued)
YES NO (If NO, proceed to Section 25)
Have you EVER received counseling or treatment as a result of your use of alcohol in addition to what
you have already listed on this form?
Complete the following if you responded 'Yes' to having EVER received counseling or treatment as a result of your use of alcohol.
Entry #1
Provide the full address of the counseling/treatment provider. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Name
Provide the name of individual counselor or treatment provider.
Provide the address of agency/organization where counseling/treatment was provided. (
Provide City and Country if outside the United States;
otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Same as above
Provide the dates of counseling or treatment.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Name
Provide the name of agency/organization where counseling/treatment was provided.
Page 113
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
(Provide name of government)
25.1
Date the investigation was completed
(Month/Year)
Est.
I don't know
Provide the date clearance eligibility/access was granted.
(Month/Year)
Est.
I don't know
(Provide name of government)
Date the investigation was completed
(Month/Year)
Est.
I don't know
Provide the date clearance eligibility/access was granted.
(Month/Year)
Est.
I don't know
Entry #2
Provide the investigating agency:
U.S. Department of Defense
U.S. Department of State
U.S. Office of Personnel Management
Federal Bureau of Investigation
U.S. Department of Treasury
U.S. Department of Homeland Security
Foreign government
I don't know
Other (Provide explanation)
Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.
Provide the level of clearance eligibility/access granted:
None
Confidential
Secret
Top Secret
Sensitive Compartmented Information (SCI)
Q
L
I don't know
Other
(Provide explanation)
Issued by foreign country
Section 25 - Investigations and Clearance Record
YES NO (If NO, proceed to 25.2)
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you
a security clearance eligibility/access?
Complete the following if you responded 'Yes' to the U.S. Government (or a foreign government) having investigated your background and/or having
granted you a security clearance eligibility/access.
Entry #1
Provide the investigating agency:
U.S. Department of Defense
U.S. Department of State
U.S. Office of Personnel Management
Federal Bureau of Investigation
U.S. Department of Treasury
U.S. Department of Homeland Security
Foreign government
I don't know
Other (Provide explanation)
Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.
Provide the level of clearance eligibility/access granted:
None
Confidential
Secret
Top Secret
Sensitive Compartmented Information (SCI)
Q
L
I don't know
Other (Provide explanation)
Issued by foreign country
(Provide name of bureau)
(Provide name of bureau)
Page 114
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
25.2
Entry #2
Provide the date security clearance
eligibility/access authorization was denied,
suspended or revoked. (Month/Year)
Est.
Provide the name of the agency that took
the action.
Provide an explanation of the circumstances of the
denial,suspension or revocation action.
25.3
Provide the name of the government
agency taking debarment action.
Est.
Provide the date the debarment occurred.
(Month/Year)
Provide the name of the government
agency taking debarment action.
Est.
Provide the date the debarment occurred.
(Month/Year)
Entry #2
Provide an explanation of the circumstances of the
debarment.
Section 25 - Investigations and Clearance Record - (Continued)
YES NO (If NO, proceed to 25.3)
Have you EVER had a security clearance eligibility/access authorization denied, suspended, or
revoked? (Note: An administrative downgrade or administrative termination of a security clearance is
not a revocation.)
Complete the following if you responded 'Yes' to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.
Entry #1
Provide the date security clearance
eligibility/access authorization was denied,
suspended or revoked. (Month/Year)
Est.
Provide the name of the agency that took
the action.
Provide an explanation of the circumstances of the
denial,suspension or revocation action.
YES NO (If NO, proceed to Section 26)
Have you EVER been debarred from government employment?
Complete the following if you responded 'Yes' to having EVER been debarred from government employment.
Entry #1
Provide an explanation of the circumstances of the
debarment.
Page 115
Section 26 - Financial Record
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
Provide the bankruptcy court docket/account number.
Provide the date bankruptcy was
filed.
(Month/Year)
Est.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to 26.2)
Complete the following if you responded 'Yes' to in the last seven (7) years having filed a petition under any chapter of the bankruptcy code.
Chapter 7 Chapter 11 Chapter 12 Chapter 13
Select the applicable bankruptcy petition type.
Est.
Provide the date of bankruptcy
discharge.
(Month/Year)
Not Applicable
Entry #1
Provide the total amount (in U.S.
dollars) involved in the bankruptcy.
Est.
Provide the name debt is recorded under.
Provide the address of the court involved. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the address of the trustee for this bankruptcy. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the name of the trustee for this bankruptcy.
Were you discharged of all debts claimed in the bankruptcy?
Provide Explanation.
(a) If Chapter 13 previously selected:
Provide the name of the court involved.
26.1
NO (Provide explanation)YES (Provide explanation)
Provide the bankruptcy court docket/account number.
Provide the date bankruptcy was
filed.
(Month/Year)
Est.
Chapter 7 Chapter 11 Chapter 12 Chapter 13
Select the applicable bankruptcy petition type.
Est.
Provide the date of bankruptcy
discharge.
(Month/Year)
Not Applicable
Entry #2
Provide the total amount (in U.S.
dollars) involved in the bankruptcy.
Est.
Provide the name debt is recorded under.
Provide the address of the court involved. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Suffix
Middle name
Last name
First name
Provide the address of the trustee for this bankruptcy. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the name of the trustee for this bankruptcy.
Were you discharged of all debts claimed in the bankruptcy?
Provide Explanation.
(a) If Chapter 13 previously selected:
Provide the name of the court involved.
NO (Provide explanation)YES (Provide explanation)
Page 116
Section 26 - Financial Record - (Continued)
Have you EVER experienced financial problems due to gambling?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to 26.3)
Complete the following if you responded 'Yes' to having EVER experienced financial problems due to gambling.
26.2
Entry #1
Provide a description of your financial problems due to gambling.
Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.Provide the date range of your financial problems due to gambling.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
If you have taken any action(s) to rectify your financial problems due to gambling, provide
a description of your actions. If you have not taken any action(s), provide explanation.
Entry #2
Provide a description of your financial problems due to gambling.
Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.Provide the date range of your financial problems due to gambling.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
If you have taken any action(s) to rectify your financial problems due to gambling, provide
a description of your actions. If you have not taken any action(s), provide explanation.
In the last seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law
or ordinance?
Provide the year you failed to file or pay your Federal, state, or other taxes.
YES NO (If NO, proceed to 26.4)
Complete the following if you responded 'Yes' to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
File Pay Both
Did you fail to file, pay as required, or both?
Est.
Provide date satisfied.
(Month/Year)
Not Applicable
Entry #1
Provide the Federal, state, or other agency
to which you failed to file or pay taxes.
Provide a description of 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) provide explanation.
Provide the reason(s) for your failure to file or pay required taxes. Provide the type of taxes you failed to file or
pay (such as property, income, sales, etc.).
Provide the amount (in U.S. dollars) of the taxes.
Est.
26.3
Provide the year you failed to file or pay your Federal, state, or other taxes.
File Pay Both
Did you fail to file, pay as required, or both?
Est.
Provide date satisfied.
(Month/Year)
Not Applicable
Entry #2
Provide the Federal, state, or other agency
to which you failed to file or pay taxes.
Provide a description of 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) provide explanation.
Provide the reason(s) for your failure to file or pay required taxes. Provide the type of taxes you failed to file or
pay (such as property, income, sales, etc.).
Provide the amount (in U.S. dollars) of the taxes.
Est.
Est.
Est.
Page 117
Section 26 - Financial Record - (Continued)
In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of
agreement for a travel or credit card provided by your employer?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to 26.5)
Complete the following if you responded 'Yes' to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card
provided by your employer.
Entry #1
Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any
action(s) provide explanation.
Provide the date of your counseling, warning, or disciplinary action.
Est.
Provide the name of the agency or company.
Provide the address of the agency or company.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the reason(s) for the counseling, warning, or disciplinary action.
26.4
(Month/Year)
Est.
Provide the amount (in U.S. dollars)
of violation.
Entry #2
Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any
action(s) provide explanation.
Provide the date of your counseling, warning, or disciplinary action.
Est.
Provide the name of the agency or company.
Provide the address of the agency or company.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the reason(s) for the counseling, warning, or disciplinary action.
(Month/Year)
Est.
Provide the amount (in U.S. dollars)
of violation.
Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to
resolve your financial difficulties?
YES NO (If NO, proceed to 26.6)
Complete the following if you responded 'Yes' to being currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to
resolve your financial difficulties.
Entry #1
As a result of this counseling, provide a description of any action(s) you have taken to resolve your financial difficulties. If you have not taken any action(s),
provide explanation.
Provide explanation.
Provide the location of the credit counseling organization.
City
State
Telephone number
Extension
Provide the telephone number of the credit counseling organization.
International or DSN phone number
Day Night
Provide the name of the credit counseling organization or resource.
Entry #2
As a result of this counseling, provide a description of any action(s) you have taken to resolve your financial difficulties. If you have not taken any action(s),
provide explanation.
Provide explanation.
Provide the location of the credit counseling organization.
City
State
Telephone number
Extension
Provide the telephone number of the credit counseling organization.
International or DSN phone number
Day Night
Provide the name of the credit counseling organization or resource.
26.5
Page 118
Section 26 - Financial Record - (Continued)
Other than previously listed, have any of the following happened to you? (You will be asked to provide
details about each financial obligation that pertains to the items identified below)
- In the last seven (7) years, you have been delinquent on alimony or child support payments.
- In the last seven (7) years, you had a judgment entered against you. (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner
or guarantor).
- In the last seven (7) years, you had a lien placed against your property for failing to pay taxes
or other debts. (Include financial obligations for which you were the sole debtor, as well as
those for which you were a cosigner or guarantor).
- You are currently delinquent on any Federal debt. (Include financial obligations for which you
are the sole debtor, as well as those for which you are a cosigner or guarantor).
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, Proceed to 26.7)
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Provide a description of 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), provide explanation.
Provide the associated loan/account number(s) involved.
Est.
Did/does this financial issue include any of the following? (Check all that apply)
Entry #1
Identify/describe the type of property involved (if any).
Provide the reason(s) for the financial issue.
Provide the current status of the financial issue.
Provide the date the financial
issue began. (Month/Year)
Est.
Provide date the financial issue
was resolved.
(Month/Year)
Est.
Provide the name of the court involved.
Provide the address of the court involved.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the amount (in U.S. dollars) of the financial issue.
Provide the name of agency/organization/individual to which debt is/was owed.
Not Resolved
In the last seven (7) years, you have been delinquent on alimony or child support payments.
In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those
for which you were a cosigner or guarantor).
In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).
26.6
YES NO (If NO, Proceed to 26.7)
Page 119
Section 26 - Financial Record - (Continued)
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
Provide a description of 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), provide explanation.
Provide the associated loan/account number(s) involved.
Est.
Did/does this financial issue include any of the following? (Check all that apply)
Entry #2
Identify/describe the type of property involved (if any).
Provide the reason(s) for the financial issue.
Provide the current status of the financial issue.
Provide the date the financial
issue began. (Month/Year)
Est.
Provide date the financial issue
was resolved.
(Month/Year)
Est.
Provide the name of the court involved.
Provide the address of the court involved.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide the amount (in U.S. dollars) of the financial issue.
Provide the name of agency/organization/individual to which debt is/was owed.
Not Resolved
In the last seven (7) years, you have been delinquent on alimony or child support payments.
In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those
for which you were a cosigner or guarantor).
In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a
cosigner or guarantor).
YES NO (If NO, Proceed to 26.7)
Page 120
Section 26 - Financial Record - (Continued)
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to Section 27)
Provide a description of 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), provide explanation.
Provide the associated loan/account number(s) involved.
Est.
Did/does this financial issue include any of the following? (Check all that apply)
YES NO (If NO, proceed to Section 27)
In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
Entry #1
Identify/describe the type of property involved (if any).
Provide the reason(s) for the financial issue. Provide the current status of the financial issue.Provide the amount (in U.S. dollars) of the financial issue.
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?
In the last seven (7) years, you were over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were
the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you
are a cosigner or guarantor).
Provide the name of agency/organization/individual to which debt is/was owed.
Provide the date the financial issue began. (Month/Year)
Est.
Provide date the financial issue was resolved.
(Month/Year)
Est.
Not Resolved
Other than previously listed, have any of the following happened?
- In the last seven (7) years, you had any possessions or property voluntarily or involuntarily
repossessed or foreclosed? (Include financial obligations for which you were the sole debtor,
as well as those for which you were a cosigner or guarantor).
- In the last seven (7) years, you defaulted on any type of loan? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a
cosigner or guarantor).
- In the last seven (7) years, you had bills or debts turned over to a collection agency?
(Include financial obligations for which you were the sole debtor, as well as those for which
you were a cosigner or guarantor).
- In the last seven (7) years, you had any account or credit card suspended, charged off, or
cancelled for failing to pay as agreed? (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
- In the last seven (7) years, you were evicted for non-payment?
- In the last seven (7) years, you had wages, benefits, or assets garnished or attached
for any reason?
- In the last seven (7) years, you were over 120 days delinquent on any debt not
previously entered? (Include financial obligations for which you were the sole debtor, as well
as those for which you were a cosigner or guarantor).
- You are currently over 120 days delinquent on any debt? (Include financial obligations for
which you are the sole debtor, as well as those for which you are a cosigner or guarantor).
26.7
In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor,
as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you were evicted for non-payment?
Page 121
Section 26 - Financial Record - (Continued)
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Provide a description of 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), provide explanation.
Provide the associated loan/account number(s) involved.
Est.
Did/does this financial issue include any of the following? (Check all that apply)
YES NO (If NO, proceed to Section 27)
In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
Entry #2
Identify/describe the type of property involved (if any).
Provide the reason(s) for the financial issue. Provide the current status of the financial issue.Provide the amount (in U.S. dollars) of the financial issue.
Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.
In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?
In the last seven (7) years, you were over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were
the sole debtor, as well as those for which you were a cosigner or guarantor).
You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you
are a cosigner or guarantor).
Provide the name of agency/organization/individual to which debt is/was owed.
Provide the date the financial issue began. (Month/Year)
Est.
Provide date the financial issue was resolved.
(Month/Year)
Est.
Not Resolved
In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor,
as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
In the last seven (7) years, you were evicted for non-payment?
Page 122
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
27.1
(Month/Year)
(Month/Year)
Entry #2
Provide the location where the incident took place. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Est.
Provide the date of the incident.
Provide a description of the nature of the incident or offense.
(Month/Year)
Entry #1
Provide the location where the incident took place. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Est.
Provide the date of the incident.
Provide a description of the nature of the incident or offense.
(Month/Year)
Entry #2
Provide the location where the incident took place. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Est.
Provide the date of the incident.
Provide a description of the nature of the incident or offense.
27.2
Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the above.
YES NO (If NO, proceed to 27.3)
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 attempted any of the
above?
Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into
any information technology system.
Section 27 - Use of Information Technology Systems
YES NO (If NO, proceed to 27.2)
In the last seven (7) years have you illegally or without proper authorization accessed or attempted to
access any information technology system?
Entry #1
Provide the location where the incident took place. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as
evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal
government. The following questions ask about your use of information technology systems. Information technology systems include all related computer
hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection of information.
Est.
Provide the date of the incident.
Provide a description of the nature of the incident or offense.
Page 123
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
(Month/Year)
Entry #1
Provide the location where the incident took place. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Est.
Provide the date of the incident.
Provide a description of the nature of the incident or offense.
(Month/Year)
Entry #2
Provide the location where the incident took place. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Provide a description of the action (administrative, criminal or other) taken as a result of this incident.
Est.
Provide the date of the incident.
Provide a description of the nature of the incident or offense.
27.3
Complete the following if you responded 'Yes' to having in the last seven (7) years 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.
Section 27 - Use of Information Technology Systems - (Continued)
YES NO (If NO, proceed to Section 28)
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?
Page 124
Section 28 - Involvement in Non-Criminal Court Actions
In the last ten (10) years, have you been a party to any public record civil court action not listed elsewhere on
this form?
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to Section 29)
Complete the following if you responded 'Yes' to having been a party to any public record civil court action(s) not listed elsewhere on this form in the last
ten (10) years.
Entry #1
Provide details of the nature of the action.
Provide the date of the civil action.
Provide the court name.
Provide a description of the results of the action. Provide the name(s) of the principal parties
involved in the court action.
Provide the address of the court. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Est.
(Month/Year)
Entry #2
Provide details of the nature of the action.
Provide the date of the civil action.
Provide the court name.
Provide a description of the results of the action. Provide the name(s) of the principal parties
involved in the court action.
Provide the address of the court. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Est.
(Month/Year)
Enter your Social Security Number before going to the next page
Page 125
The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an
adverse employment, security, or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are
dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.
Section 29 - Association Record
Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an
awareness of the organization's dedication to that end, or with the specific intent to further such activities?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to 29.2)
Complete the following if you responded 'YES' to being or ever having been a member of an organization dedicated to terrorism, either with an awareness of
the organization's dedication to that end, or with the specific intent to further such activities.
Entry #1
Provide all positions held in the organization, if any.
Provide the full name of the organization.
Provide a description of the nature of and reasons for your involvement with the
organization.
Provide the dates of your involvement with the organization.
No positions held
No contributions made
Provide all contributions made to the
organization, if any.
Provide the address/location of the organization.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
29.1
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #2
Provide all positions held in the organization, if any.
Provide the full name of the organization.
Provide a description of the nature of and reasons for your involvement with the
organization.
Provide the dates of your involvement with the organization.
No positions held
No contributions made
Provide all contributions made to the
organization, if any.
Provide the address/location of the organization.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Page 126
Section 29 - Association Record - (Continued)
Have you EVER knowingly engaged in any acts of terrorism?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Complete the following if you responded 'Yes' to EVER having knowingly engaged in any acts of terrorism.
Entry #1
Describe the nature and reasons for the activity.
Provide the dates for any such activities.
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
force?
Complete the following if you responded 'Yes' to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
force.
Entry #1
Provide the reason(s) for advocating acts of terrorism.
Provide the dates of advocating acts of terrorism.
YES NO (If NO, proceed to 29.3)
29.2
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
YES NO (Proceed to 29.4)
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #2
Provide the reason(s) for advocating acts of terrorism.
Provide the dates of advocating acts of terrorism.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
29.3
Entry #2
Describe the nature and reasons for the activity.
Provide the dates for any such activities.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Page 127
Section 29 - Association Record - (Continued)
Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow
the United States 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?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
YES NO (If NO, proceed to 29.5)
Complete the following if you responded 'Yes' to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the
United States 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.
Entry #1
Provide all positions held in the organization, if any.
Provide the full name of the organization.
Provide a description of the nature of and reasons for your involvement with the
organization.
Provide the dates of your involvement with the organization.
No positions held
No contributions made
Provide all contributions made to the
organization, if any.
Provide the address/location of the organization.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
29.4
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #2
Provide all positions held in the organization, if any.
Provide the full name of the organization.
Provide a description of the nature of and reasons for your involvement with the
organization.
Provide the dates of your involvement with the organization.
No positions held
No contributions made
Provide all contributions made to the
organization, if any.
Provide the address/location of the organization.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Page 128
Section 29 - Association Record - (Continued)
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?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Complete the following if you responded 'Yes' to being or EVER having 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 that of any state of the U.S. with the specific intent to further
such action.
Entry #1
Provide all positions held in the organization, if any.
Provide the full name of the organization.
Provide a description of the nature of and reasons for your involvement with the
organization.
Provide the dates of your involvement with the organization.
No positions held
No contributions made
Provide all contributions (in U.S. dollars)
made to the organization, if any.
Provide the address/location of the organization. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
29.5
YES NO (If NO, proceed to 29.6)
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #2
Provide all positions held in the organization, if any.
Provide the full name of the organization.
Provide a description of the nature of and reasons for your involvement with the
organization.
Provide the dates of your involvement with the organization.
No positions held
No contributions made
Provide all contributions (in U.S. dollars)
made to the organization, if any.
Provide the address/location of the organization.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
Page 129
Section 29 - Association Record - (Continued)
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Complete the following if you responded 'Yes' to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Entry #1
Describe the nature and reasons for the activity.
Provide the dates of such activities.
Have you EVER associated with anyone involved in activities to further terrorism?
Complete the following if you responded 'Yes' to having EVER associated with anyone involved in activities to further terrorism.
Entry #1
Provide explanation.
Entry #2
Provide explanation.
29.6
YES NO (If NO, proceed to 29.7)
Present
From Date (Month/Year)
Est.
To Date (Month/Year)
Est.
Entry #2
Describe the nature and reasons for the activity.
Provide the dates of such activities.
Present
From Date
(Month/Year)
Est.
To Date (Month/Year)
Est.
YES NO
29.7
Continuation Space
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Use the space below to continue answers or a blank sheet(s) of paper. Include your name and SSN at the top of each blank sheet(s). Before each
answer, identify the number of the item and attempt to maintain sequential order and question format.
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 the attached release(s).
Certification
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
further affirm that, to the best of my knowledge, I have not included any classified information herein. I have carefully read the foregoing instructions to
complete this form. 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, falsifying, or including classified information may have a negative effect 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 signed (mm/dd/yyyy)
Page 130
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
AUTHORIZATION FOR RELEASE OF INFORMATION
UNITED STATES OF AMERICA
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, reinvestigation, or ongoing evaluation (i.e. continuous evaluation) of my eligibility for access to classified
information or, when applicable, eligibility to hold a national security sensitive position 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 current
and historic academic, residential, achievement, performance, attendance, disciplinary, employment, criminal, financial, and credit
information, and publicly available social media information. I authorize the Federal agency conducting my investigation, reinvestigation, or
ongoing evaluation (i.e. continuous evaluation) of eligibility to disclose the record of investigation or ongoing evaluation to the requesting
agency for the purpose of making a determination of suitability, or initial or continued eligibility for a national security position or eligibility for
access to classified information.
I Understand that, for these purposes, publicly available social media information includes any electronic social media information that has
been published or broadcast for public consumption, is available on request to the public, is accessible on-line to the public, is available to
the public by subscription or purchase, or is otherwise lawfully accessible to the public. I further understand that this authorization does not
require me to provide passwords; log into a private account; or take any action that would disclose non-publicly available social media
information.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and
date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management
(OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide
explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of
information, separate specific releases may be needed, and I may be contacted for such releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of Investigation, the
Department of Defense, the Department of Homeland Security, the Office of the Director of National Intelligence, the Department of State,
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 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 86, and that it may be disclosed by the Government only as authorized by law.
I Authorize the information to be used to conduct officially sanctioned and approved personnel security-related studies and analyses, which
will be maintained in accordance with the Privacy Act.
Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I occupy a national security
sensitive position or require eligibility for access to classified information.
Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used
Social Security Number
Current street address Apt. #
City (Country)
State ZIP Code
Telephone number
Date of birth
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
If you answered "Yes" to Section 21 of the Standard Form 86 (SF-86), carefully read this authorization to release information about you, then
sign and date it in ink.
This is an authorization for the investigator to ask your health practitioner(s) the questions below concerning your mental health consultations.
The U.S. government recognizes the critical importance of mental health and advocates proactive management of mental health conditions to
support the wellness and recovery of Federal employees and others. The government recognizes that mental health counseling and treatment
may provide important support for those who have experienced traumatic events, as well as for those with other mental health conditions.
While most individuals with mental health conditions do not present security risks, there may be times when such a condition can affect a
person’s eligibility for a security clearance. Seeking or receiving mental health care for personal wellness and recovery may contribute
favorably to decisions about your eligibility. Your signature will allow the practitioner(s) to answer only those questions identified below.
Authorization
I am seeking assignment to or retention in a national security sensitive position. 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,
reinvestigation, or ongoing evaluation (i.e., continuous evaluation) of eligibility for access to classified information or eligibility to hold a national
security sensitive position to request, and my health practitioner(s) to provide, the information requested below, relating to my mental health
consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to my health care provider/
entity. Revocation of this authorization is not effective until received by my health care provider/entity. I understand that I may revoke this
authorization, except to the extent that action has already been taken based on this authorization. Further, I understand that this authorization
is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this
disclosure.
I understand the information disclosed pursuant to this authorization for use by the Federal Government only for purposes provided in the
Standard Form 86 will no longer be covered by the HIPAA Privacy Rule, and that the Federal Government may redisclose the information as
authorized by law, subject to Privacy Act safeguards.
Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed or upon
termination of my affiliation with the Federal Government, whichever is sooner.
For Use By Practitioner(s) Only
Does the person under investigation have a condition that could impair his or her judgment, reliability, or trustworthiness?
YES NO
Signature (Sign in ink)
Practitioner name
Date signed (mm/dd/yyyy)
What is the prognosis?
Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used
Social Security Number
Current street address Apt. #
City (Country)
State ZIP Code
Telephone number
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
Dates of treatment?
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised November 2016
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
UNITED STATES OF AMERICA
FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit
Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
The Federal government requires information from one or more consumer reporting agencies in order to obtain information in
connection with a background investigation, reinvestigation, or ongoing evaluation (i.e. continuous evaluation) of eligibility for
access to classified information, or when applicable, eligibility to hold a national security sensitive position. The information
obtained may be disclosed to other Federal agencies for the above purposes in fulfillment of official responsibilities to the extent
that such disclosure is permitted by law. Information from the consumer report will not be used in violation of any applicable
Federal or state equal employment opportunity law or regulation.
Authorization
I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my initial background investigation, reinvestigation, or ongoing evaluation (i.e. continuous evaluation) of my eligibility
for access to classified information, or when applicable, eligibility to hold a national security sensitive position to request, and
any consumer reporting agency to provide, such reports for purposes described above.
Note: If you have a security freeze on your consumer or credit report file, we will not be able to access the information
necessary to complete your investigation, which can adversely affect your eligibility for a national security position. To avoid
such delays, you should expeditiously respond to any requests made to release the credit freeze for the purposes as described
above.
Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I occupy a
national security sensitive position or require eligibility for access to classified information.
Signature (Sign in ink)
Print Name
Date signed (mm/dd/yyyy)
Social Security Number
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Sf86 Standard Form 86 - Questionnaire for National Security

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Completed 4 December 2019

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