The Department defines cohabitation as living together in a spouse-like relationship. It includes the mutual assumption of
those marital rights, duties and obligations which are usually manifested by married people, including but not necessarily
dependent on sexual relations.
In order for the Department to conduct a review of the FBI criminal history files pertaining to you, 5 USC 9101 requires
the Department to obtain your written consent. By affixing your signature below, you authorize any duly accredited
representative of the Department of State to request criminal history record information about you from the FBI for the
purpose of determining your spouse or cohabitant's eligibility for access to classified information and/or assignment to, or
retention in, a sensitive National Security position, in accordance with 5 USC 9101. Information we collect during an
investigation may be disclosed without your consent only as permitted by the Privacy Act Routine Uses enumerated on
Standard Form 86 completed by your spouse or cohabitant.
Carefully read this authorization to release information, then sign and date it in ink.
The Department of State is conducting a personnel security background investigation on your spouse or cohabitant to
determine his or her eligibility for access to classified information. The Department must comply with Executive Order
12968 and the investigative Standards for Background Investigations for Access to Classified information published in
32 CFR 147. As part of your spouse's or cohabitant's investigation, the Department is required to conduct a National
Agency Check, without fingerprint cards, on you.
By definition, the National Agency Check consists of a review of:
(a) investigative and criminal history files of the FBI;
(b) OPM's Security/Suitability Investigations Index (SII);
(c) DoD's Defense Clearance and Investigations Index (DCII);
(d) such other national agencies checks (e.g., Joint Personnel Adjudicative System (JPAS)) as appropriate to the
individual's background.
Date (mm-dd-yyyy)
Social Security Number
Date of Birth (mm-dd-yyyy)
(Last, First, Middle)
Privacy Act: The information solicited on this form is requested under the authority of Executive Order 12968 and as specifically noted in 5
U.S.C. 9101. The primary purpose for soliciting this information is to obtain written consent to conduct FBI criminal history checks on the
spouse/cohabitant of the subject of a personnel security investigation for a national security position. The information solicited on this form may
be made available as a routine use to other government agencies to assist the U.S. Department of State in conducting personnel background
investigations and for law enforcement and administrative purposes. Failure to provide the information requested on this form may result in the
administrative withdrawal of security clearance processing for the applicant/employee. Disclosure of this information is mandatory to comply with
investigative standards set forth in Executive Order 12968.
U.S. Department of State
Applicant/Employee Name (Last, First, Middle)
Name of Spouse or Cohabitant (Please Print)
Place of Birth (City, State, Country)
Signature of Spouse or Cohabitant
click to sign
click to edit