Preproposal Conference Sign-In Sheet and Handout.pdf

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PREPROPOSAL CONFERENCE Page 1 of 4

PREPROPOSAL CONFERENCE

GS05P10SPC0026

July 13, 2010 @ 10:00AM (local time)

NOTICE: Any remarks or explanations provided by a Government representative during this conference do not change the terms and conditions of the solicitation. Any change to the solicitation will be issued by amendment (SF30).

1. PROJECT IDENTIFICATION

Exterior Restoration & Solarium Redesign (RMI00210) Kalamazoo Federal Building & U.S. Courthouse, 410 W Michigan Ave, Kalamazoo, MI

2. SCOPE OF WORK

The intent of this contract is to provide Exterior Restoration and a Solarium Redesign at the Kalamazoo Federal Building & U.S. Courthouse, Kalamazoo, Michigan. The restoration of this 60 plus year old significant building requires some techniques that are not typically encountered in new construction projects. This requirement includes concrete curb construction, masonry cleaning of the entire building, masonry repairs, sidewalk replacement, new doors, resealing of the windows and masonry, waterproofing, painting, and solarium and guardrail replacement.

3. WORK RESTRICTIONS/CONTRACTOR USE OF PREMISES

The Contractor working hours shall be generally established to occur during normal business hours, however portions of the work shall be completed on weekends or outside normal business hours.

No parking will be available on site. The Contractor and Contractor’s employees shall make their own arrangements for vehicle parking off site. Additional parking that may be necessary in the building for delivery of materials or equipment shall be coordinated in advance with the GSA Property Management Office.

4. PROJECT MAGNITUDE

The estimated price range of this project is between $100,000 and $250,000.

5. PERFORMANCE TIME & LIQUIDATED DAMAGES

You will have 310 calendar days after notice to proceed to complete the work. Liquidated damages are $337.73 per day.

An Interim Notice to Proceed will be issued at the time of award permitting the Contractor to: (1) apply for and obtain security clearances, (2) prepare and submit project schedules, shop drawings and material submittals, (3) order materials and equipment, (4) perform any other off-site work, and (5) submit required insurance and bonds. Notice to Proceed will be issued upon verification that the Contractor has received approved security clearances for a suitable number of employees to begin on-site work and receipt of acceptable insurance and bond coverage.

REFERENCE: FAR 52.211-10 COMMENCEMENT, PROSECUTION AND COMPLETION OF WORK

FAR 52.211-12 LIQUIDATED DAMAGES - CONSTRUCTION

6. SECURITY REQUIREMENTS

This solicitation includes Sensitive But Unclassified (SBU) building information. SBU documents provided under this solicitation are intended for use by authorized users only. In support of this requirement, GSA requires offerors to exercise reasonable care when handling documents relating to SBU building information. You shall review the SBU information contained in the Representations & Certifications section of the solicitation and comply as applicable.

Contract employees will be required to have a Government security clearance or other Government authorization to perform work on federal property. To obtain clearance, contract employees may be required to provide personal identifying information such as name, date of birth and social security number. Contract employees may also be required to provide employment, residence, and education history as well as citizenship and family information. You should review the attached

U.S. General Services Administration

PREPROPOSAL CONFERENCE Page 2 of 4

Standard Form 85P for the type and extent of information that may be required. Specific clearance procedures for this project will be provided after award.

REFERENCE: SPECIFICATION SECTION 01593, SECURITY REGULATIONS

GSA ORDER PBS 3940.1A SAFEGUARDING AND DISSEMINATION OF SENSITIVE BUT UNCLASSIFIED (SBU)

BUILDING INFORMATION

7. BONDS & INSURANCE

A bid bond (20% of bid price) is required to be submitted with your proposal. Within 10 days after award, prior to commencing on-site work, the contractor will be required to furnish (1) a performance bond in the amount of 100% of the original contract price, (2) a payment bond in the amount of 100% of the contract price, and (3) insurance in the amounts stipulated in Section 00800 (Supplementary Conditions), paragraph 11.

REFERENCE: FAR 52.228-1 BID GUARANTEE

FAR 52.228-5, GSAR 552.228-5 INSURANCE—WORK ON A GOVERNMENT INSTALLATION

FAR 52.228-15 PERFORMANCE AND PAYMENT BONDS—CONSTRUCTION

GSAR 552.228-70 WORKERS’ COMPENSATION LAWS

8. HUBZone SET-ASIDE This procurement will be a Historically Underutilized Business Zone (HUBZone) Program set-aside in accordance with FAR

19.13 and will be solicited as a competed HUBZone set-aside; therefore, open to HUBZone businesses only. The NAICS Code for this procurement is 236220 with a size standard of $33.5 million. Offerors shall register their firms in the Online Representations & Certifications (ORCA) system prior to submitting their offer and ensure that the assigned NAICS is listed in the record. The ORCA record must be current, accurate, and complete verifying the applicability to this solicitation, or the offeror shall provide supplemental information in their proposal package certifying this information as of the date of the offer.

REFERENCE: FAR 52.204-8 ANNUAL REPRESENTATIONS AND CERTFICIATIONS

9. SUBCONTRACTING

It is the policy of the United States that small business concerns, veteran-owned small business concerns, service-disabled veteran-owned small business concerns, HUBZone small business concerns, small disadvantaged business concerns, and women-owned small business concerns shall have the maximum practicable opportunity to participate in performing contracts let by any Federal agency, including contracts and subcontracts. It is further the policy of the United States that its prime contractors establish procedures to ensure the timely payment of amounts due pursuant to the terms of their subcontracts. The Contractor hereby agrees to carry out this policy in the awarding of subcontracts to the fullest extent consistent with efficient contract performance. The Contractor further agrees to cooperate in any studies or surveys as may be conducted by the United States Small Business Administration or the awarding agency of the United States as may be necessary to determine the extent of the Contractor’s compliance with this clause.

The Contractor shall not enter into any subcontract in excess of $30,000 with a Contractor that is debarred, suspended, or proposed for debarment unless there is a compelling reason to do so. The Contractor shall notify the Contracting Officer, in writing, before entering into a subcontract with a party that is debarred, suspended, or proposed for debarment.

Nothing contained in the contract shall be construed as creating any contractual relationship between any subcontractor and the Government. The divisions or sections of the specifications are not intended to control the Contractor in dividing the work among subcontractors, or to limit the work performed by any trade. The Contractor shall be responsible to the Government for acts and omissions of his own employees and of subcontractors and their employees. He shall also be responsible for the coordination of the work of the trades, subcontractors and suppliers. The Government will not undertake to settle any differences between or among the Contractor, subcontractors, or suppliers.

The Contractor shall be responsible to the Government for acts and omissions of his own employees and of subcontractors and their employees. He shall also be responsible for the coordination of the work of the trades, subcontractors and suppliers.

The Government will not undertake to settle any differences between or among the Contractor, subcontractors, or suppliers.

NOTE: In accordance with FAR 52.219-3(c)(3), For general construction, at least 15 percent of the cost of the contract performance incurred for personnel will be spent on the concern’s employees or the employees of other HUBZone small business concerns.

REFERENCE: FAR 52.219-8 UTILIZATION OF SMALL BUSINESS CONCERNS

PREPROPOSAL CONFERENCE Page 3 of 4

FAR 52.209-6 PROTECTING THE GOVERNMENT’S INTEREST WHEN SUBCONTRACTING WITH CONTRACTORS

DEBARRED, SUSPENDED, OR PROPOSED FOR DEBARMENT

FAR 52.219-3 NOTICE OF TOTAL HUBZONE SET-ASIDE

GSAR 552.236-82 SUBCONTRACTS

10. SITE VISIT

All other site visits will be based on the availability of the Property Management staff and may be arranged during normal duty hours by contacting: Fred McWain, Property Manager, at (616) 456-2692.

11. BASIS OF AWARD

The Government will award a contract resulting from this solicitation to the responsible offeror whose proposal conforms to the solicitation and provides the best value to the Government, based on the evaluation factors. Two factors will be evaluated: (1) past performance and (2) total evaluated price. Past performance is significantly more important than total evaluated price. As proposals become more equal in terms of past performance, the total evaluated price becomes more important.

Note: The Government intends to evaluate proposals and award a contract without discussions with offerors.

Therefore, the offeror's initial proposal should contain the offeror's best terms from a cost or price and technical standpoint. The Government reserves the right to conduct discussions if the Contracting Officer later determines them to be necessary. The Government reserves the right to make an award to other than the lowest priced offer if it is determined that to do so would result in the best value to the Government.

12. DESCRIPTION OF EVALUATION FACTORS

A. PAST PERFORMANCE

Past performance is relevant information regarding an offeror’s actions under previously awarded contracts. It includes the offeror’s overall quality of performance, record of conforming to contract requirements and to standards of good workmanship; the offeror’s adherence to contract schedules, including the administrative aspects of performance; the responsiveness of management; the offeror’s history of reasonable and cooperative behavior and commitment to customer satisfaction, including the offeror’s business-like concern for the interest of the customer; and the offeror’s overall performance on their contracts.

To be relevant, past performance information must be provided for contracts that are: (1) The contract was for restoration, masonry, and associated general construction in a commercial or government-owned facility (2) Past contract was completed no more than five years from the closing date of this solicitation (3) Current contract is at least 90% complete.

The offeror shall submit 3-7 references using Attachment A–Past Performance Reference provided in the solicitation. This form must be completed for each reference submitted that meets the relevancy criteria. The offeror cannot use the same reference/contact person more than once.

B. TOTAL EVALUATED PRICE

A lump sum offer is required for all the work shown on the drawings and specifications. The Price evaluation factor will consist of only the lump sum offer provided on the Standard Form 1442. A unit price is also required (see Section 01270) which will be accepted or rejected at time of award, to be applied towards change order work as required over the course of the project. The Government will use various price analysis techniques and procedures (e.g., comparison of proposed prices received in response to the solicitation, comparison of proposed prices with independent Government cost estimates) to ensure a fair and reasonable price.

Only proposals for a complete project will be accepted and not proposals for materials and/or separate labor disciplines.

13. PROPOSAL SUBMISSION & CONTENTS

Offers are currently due on August 2, 2010 at 3:00PM (local time) to the attention of Ms. Joslann Gray in the office location specified in block 8 of the SF1442. Any change to the due date would be issued by amendment only.

Proposals and modifications to proposals shall be submitted in paper media in sealed envelopes or packages addressed to the office specified in the solicitation and showing the time and date specified for receipt, the solicitation number, and the name and. address of the offeror. Offerors using commercial carriers should ensure that the proposal is marked on the outermost wrapper with this information.

PREPROPOSAL CONFERENCE Page 4 of 4

Hand-carried proposals must be at the front desk of the identified GSA office by the date and time specified for receipt of offers. Note that all visitors to the Federal Building will be subject to a security screening at the building entrance.

Facsimile, email or other electronic methods are not permitted

A complete proposal submission consists of the following fully-completed documents:

1. Proposal Coversheet

2. Standard Form 1442

3. Standard Form 24

4. GSA Form 527

5. Past Performance References

6. Substitute GSA Form 3503

7. Amendments, if applicable

Do not return the entire solicitation. You do not need to use a 3-ring binder or other binding methods. When signature is required, ensure you provide original signatures. Alternate proposals will not be accepted. Fax or other electronic submission of proposals is not authorized.

The offeror should ensure that the following web-based records are active, accurate and complete based on the NAICS assigned to this procurement:

1. Central Contractor Registration (CCR) [www.ccr.gov]

2. Online Representations and Certifications (ORCA) [http://orca.bpn.gov]

The offeror shall also ensure that company name and address information stated on any proposal document matches the information contained in CCR (down to the commas and periods).

Alternate proposals will not be accepted. Fax or other electronic submission of proposals is not authorized.

REFERENCE: FAR 52.215-1 INSTRUCTIONS TO OFFERORS—COMPETITIVE ACQUISITION

FAR 52.236-28 PREPARATION OF PROPOSALS—CONSTRUCTION

14. INFORMATION CONCERNING THE DISCLOSURE OF BID/PROPOSAL RESULTS

This acquisition is being conducted under the provisions of FAR Part 15 as a negotiated procurement. In accordance with FAR 3.104 and FAR 15.207, no information regarding the identity of those submitting offers, the number of offers received, or the information contained in such offers will made available until after award except as provided by FAR 15.503.

Do not call at the time of closing to inquire about results of the award – award decisions take time. All offerors will be notified regarding the status of their proposal and any resulting award.

15. CHANGES TO THE SOLICITATION

Any change to the solicitation will be issued by amendment. Amendment 001 was issued July 12, 2010. Offerors will be responsible for monitoring FedBizOpps for amendments and/or additional information. Amendments must be acknowledged by the offeror.

16. QUESTIONS

Questions regarding the solicitation (specifications, drawings, etc.) raised outside of this conference shall be submitted to the Government point of contact indicated in item 9 of the Standard Form 1442 not less than 15 calendar days prior to the date established for receipt of offers. Currently July 19, 2010 would be the last day to submit questions. All questions shall be submitted in writing.

Do not call the architect! Contact with the Property Manager shall be limited to coordination of site visits.

MSC/PT Updated: July 12, 2010

Orientation to Contractor Clearance Process

The Contractor shall appoint a Company Point of Contact (POC) to coordinate security clearances for all contract employees (including subcontractors) that will require access to federal property.

The Contractor will submit individual Contractor Information Worksheets (CIW) with Sections 1 and 2 completed and/or a mass CIW spreadsheet (including a CIW as an attachment with Section 2 completed). The GSA Sponsor will assist the Contractor in determining which process to follow.

The applicant will receive an invitation to complete the Office of Personnel Management’s Electronic Questionnaire for Investigations Processing (e-QIP) at their e-mail address provided on the CIW. The applicant has seven (7) business days to log-in and begin the e-QIP and then will have an additional seven (7) business days to complete the investigation form and submission process.

Each applicant must be fingerprinted. Fingerprints may be obtained by appointment at an available GSA office or must be taken at a local police department using FD-258 cards obtained from GSA (2 cards per applicant).

Completed application documents (e-QIP release and signature forms, fingerprint cards) should be submitted to the Security Clearance Office (SCO).

General Notes:

1. Individual applicants should process CIW forms through the Company POC.

2. All CIWs must be typed or computer generated.

3. All CIW forms are to be submitted from the Company POC to the GSA Sponsor (identified at time of award) electronically via encrypted e-mail (encryption instructions will be provided at a later date).

4. Check spam and trash folders for e-mail invitation (from @___.gov address).

5. The Standard Form 85P will serve as a guide to help applicants fill out the e-QIP.

6. The SCO will be identified at or after award.

7. Applicants will be notified of their preliminary clearance status, either favorable or unfavorable.

8. Additional agency (tenant) specific clearance forms may be required and will be provided after award.

U.S. General Services Administration

Appoint Company POC Submit

CIWs

Get Fingerprinted

Complete e-QIP

Submit Application Documents

ARRA Temporary Contractors:

Complete GSA Form 850 instead of CIW

For Official Use Only Contractor Information Worksheet (CIW)

Version 3 (Updated 11/5/09) Pg. 1 of 2

Type Contractor (Definitions on Pg. 2)

Building Support External

Embedded Child Care

ARRA Long Term Contractor

Yes

Not Applicable

ARRA Temporary (Short Term) Contractors: Use GSA Form 850

Investigation Preference e-QIP

Hardcopy

(if option offered in region)

Priority (Option available for MBI / LBI / BI only)

Routine

Expedite

Sponsoring Office Symbol

GSA Region (Options on Pg.2)

1. Contract Employee Information

Name (Last/Family) First (Given) Middle (or NMN if none) Suffix

Social Security # Date of Birth Place of Birth (POB): City POB: State Country Sex

Male Female

Home Address Street e-Mail

Address Street (line 2) Phone Number (Day) Phone Number (Cell)

City State Zip Position (Job) Title IT System Administrator

Prior Investigation

Yes No

Investigation Date Agency that Adjudicated Prior Investigation U.S. Citizen

Yes No

Non-U.S. Citizens Only: Port of Entry City and State Date of Entry Less than 3 Yrs.

U.S. Resident

Alien Registration # Citizenship Country

2. Contact Information

Company Name Company is:

Prime Sub Contractor

If Sub, Name of Prime

Task Order (TO) / Delivery Order (DO) Number

(Enter Contract Base Number if TO / DO is Not Applicable)

Contract Number Type

Task Order/Delivery Order Number

Base Contract Number

Contract Start Date Contract End Date Has

Option Yrs.

Or End Date TBD

Company Point of Contact (POC) Name POC Phone Number (Day) POC Email Address

3. Project/Work Location Information (Government site where contractor is working)

GSA Building Number Building Name Building Address

4. Type of Investigation Requested for: GSA Access Card

Non-HSPD-12 Credential (Less than 6 months) Moderate Risk (LBI / MBI) National Security - (BI - SSBI)

Low Risk - (NACI) SF-85P HIGH Risk - (BI) Child Care Worker

5. Requesting Official (Sponsor) Information

Sponsor’s Name Title Is COR/COTR

Email Address Phone Number (Day) Date Forms Were Reviewed

Alternate POC and Phone Number or Comments

6. Personnel Security Office:

OPM PIPS Inv Status e-QIP Invitation # Date e-Mail Sent

[ ] Release Form

[ ] CER

[ ] Medical Release

[ ] GSA Form3665

[ ] FD 258

[ ] CS Case

[ ] FD 258 RAP

[ ] Just

Date Received

[ ] Reviewed

[ ] Scan/TIF

Date Sent to OPM

Suitability Decision Preliminary Date

[ ] Unfavorable [ ] Favorable

Final Date

[ ] Unfavorable [ ] Favorable

Notify Preliminary Decision [ ] Email: hspd12.security@gsa.gov [ ] Email: COTR/Requesting Official [ ] Email: Subject [ ] Email: Subject’s Company

Notify Final Decision [ ] Email: hspd12.security@gsa.gov [ ] Email: COTR/Requesting Official [ ] Email: Subject [ ] Email: Subject’s Company

Contractor Information Worksheet Instructions

Version 3 (Pg. 2 of 2)

Applicability of Contractor Information Worksheet Use this Contractor Information Worksheet for all GSA contractors except ARRA temporary contractors. For all ARRA temporary contractors, use the GSA Form 850 available at http://gsa.gov/forms.

How to Enable Macros if You Are Not Able to Enter Information or Select Options Electronically If you receive an option to enable macros when you open the file, select Enable Macros.

If you are not able to make selections or enter text on the form, please adjust your macros security settings. To adjust your settings, open the file. Click on Tools, then move your cursor to Macros, then select Security. On the Security window that appears, select Low, then click OK. Save the file to your workstation. When you reopen it, the form should work properly.

Type Contractor Definitions (Any GSA Service or Office May be Associated with Building Support, Embedded Contractors):

Building Support: Building maintenance or construction support contractor Embedded: “Side-by-side” or white collar contractor providing business services, and may have staff-like access to GSA space and IT systems External: Does not access GSA building or IT systems but requires a check or investigation Child Care: Child care worker

GSA Region Options: Region 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, NCR, or CO

Transmitting the Contractor Information Worksheet Do not save completed forms on your workstation. Per GSA requirements:

If Personally Identifiable Information (PII) needs to be transmitted over the Internet, it must be sent using encryption methods defined in Chapter 5, Paragraph 7 of GSA Order CIO P 2100.1E GSA Information Technology (IT).

o All passwords must be encrypted in storage.

o All sensitive information, such as PII, as deemed by the data owner, which is transmitted outside the GSA firewall, must be encrypted. Certified encryption modules must be used in accordance with FIPS PUB 140-2, “Security requirements for Cryptographic Modules.”

o When using password generated encryption keys, a password of at least 8 characters with a combination of letters, numbers, and special characters is required. A password of at least 12 characters is recommended.

o Systems implementing encryption must follow the key management procedures and processes documented in CIO IT Security Procedural guide 09-43, “Key Management.”

If PII needs to be emailed within the GSA network, at a minimum Lotus Notes encryption is required.

For additional protection the information also can be encrypted as described in Chapter 5, Paragraph 7 of this IT security policy.

If PII needs to be sent by courier, printed, or faxed several steps should be taken. When sending PII by courier mark "signature required" when sending documents. This creates a paper trail in the event items are misplaced or lost. Don't let PII documents sit on a printer where unauthorized employees or contractors can have access to the information. When faxing information use a secure fax line. If one is not available, contact the office prior to faxing so they know information is coming and contact them after transmission to ensure they received it. For each event the best course of action is limit access of PII only to those individuals authorized to handle it, create a paper trail, and verify information reached its destination.

Submission Information Check with your GSA regional point of contact for instructions on how to submit the completed form.

Privacy Act Notice In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by the Federal Property and Administrative Services Act of 1949, as amended, and Part III of Title 5, U.S.C; O. 9397 Disclosure of the information is voluntary. This form will be used as a means to prepare and issue a credential or pass. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory investigations or prosecutions, or pursuant to a request by GSA or such other agency in connection with the firing or retention of an employee, the issuance of a security clearance, the investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit. If the individual does not provide some or any part of the requested information, the employee will not be issued a credential and will not be allowed to enter a GSA-controlled building after normal working hours or when the building is under security.

Standard Form 85P Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Form approved:

OMB No. 3206-0191

NSN 7540-01-317-7372

85-1602

Questionnaire for Public Trust Positions

Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 7 and the release on Page 8. If you have any questions, call the office that gave you the form.

Purpose of this Form

The U.S. Government conducts background investigations and reinvestigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job and/or eligible for a public trust or sensitive position. Information from this form is used primarily as the basis for this investigation. Complete this form only after a conditional offer of employment has been made.

Giving us the information we ask for is voluntary. However, we may not be able to complete your investigation, or complete it in a timely manner, if you don’t give us each item of information we request. This may affect your placement or employment prospects.

Authority to Request this Information

The U.S. Government is authorized to ask for this information under Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5, U.S. Code; and parts 5, 731, 732, and 736 of Title 5, Code of Federal Regulations.

Your Social Security number is needed to keep records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

The Investigative Process

Background investigations are conducted using your responses on this form and on your Declaration for Federal Employment (OF 306) to develop information to show whether you are reliable, trustworthy, of good conduct and character, and loyal to the United States. The information that you provide on this form is confirmed during the investigation. Your current employer must be contacted as part of the investigation, even if you have previously indicated on applications or other forms that you do not want this.

In addition to the questions on this form, inquiry also is made about a person’s adherence to security requirements, honesty and integrity, vulnerability to exploitation or coercion, falsification, mis-representation, and any other behavior, activities, or associations that tend to show the person is not reliable, trustworthy, or loyal.

Your Personal Interview

Some investigations will include an interview with you as a normal part of the investigative process. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often helps to complete your investigation faster. It is important that the interview be conducted as soon as possible after you are contacted. Postponements will delay the processing of your investigation, and declining to be interviewed may result in your investigation being delayed or canceled.

You will be asked to bring identification with your picture on it, such as a valid State driver’s license, to the interview. There are other documents you may be asked to bring to verify your identity as well.

These include documentation of any legal name change, Social Security card, and/or birth certificate.

You may also be asked to bring documents about information you provided on the form or other matters requiring specific attention.

These matters include alien registration, delinquent loans or taxes, bankruptcy, judgments, liens, or other financial obligations, agreements involving child custody or support, alimony or property settlements, arrests, convictions, probation, and/or parole.

Instructions for Completing this Form

1. Follow the instructions given to you by the person who gave you the form and any other clarifying instructions furnished by that person to assist you in completion of the form. Find out how many copies of the form you are to turn in. You must sign and date, in black ink, the original and each copy you submit.

2. Type or legibly print your answers in black ink (if your form is not legible, it will not be accepted). You may also be asked to submit your form in an approved electronic format.

3. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

4. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, agencies may modify the form consistent with your intent.

5. You must use the State codes (abbreviations) listed on the back of this page when you fill out this form. Do not abbreviate the names of cities or foreign countries.

6. The 5-digit postal ZIP codes are needed to speed the processing of your investigation. The office that provided the form will assist you in completing the ZIP codes.

7. All telephone numbers must include area codes.

8. All dates provided on this form must be in Month/Day/Year or Month/Year format. Use numbers (1-12) to indicate months. For example, June 10, 1978, should be shown as 6/10/78.

9. Whenever "City (Country)" is shown in an address block, also provide in that block the name of the country when the address is outside the United States.

10. If you need additional space to list your residences or employments/self-employments/unemployments or education, you should use a continuation sheet, SF 86A. If additional space is needed to answer other items, use a blank piece of paper. Each blank piece of paper you use must contain your name and Social Security Number at the top of the page.

Final Determination on Your Eligibility

Final determination on your eligibility for a public trust or sensitive position and your being granted a security clearance is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made.

Penalties for Inaccurate or False Statements

The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines of up to $10,000, and/or 5 years imprisonment, or both. In addition, Federal agencies generally fire, do not grant a security clearance, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Because the position for which you are being considered is one of public trust or is sensitive, your trustworthiness is a very important consideration in deciding your suitability for placement or retention in the position.

Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you give us on the form and to make your comments part of the record.

Disclosure of Information

The information you give us is for the purpose of investigating you for a position; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information is governed by the Privacy Act. The agency which requested the investigation and the agency which conducted the investigation have published notices in the Federal Register describing the system of records in which your records will be maintained. You may obtain copies of the relevant notices from the person who gave you this form. The information on this form, and information we collect during an investigation may be disclosed without your consent as permitted by the Privacy Act (5 USC 552a(b)) and as follows:

PRIVACY ACT ROUTINE USES

1. To the Department of Justice when: (a) the agency or any component thereof; or

(b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.

2. To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity;

or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.

3. Except as noted in Question 21, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order.

4. To any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested.

5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an employee, or the retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action.

6. To contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged. Such recipients shall be required to comply with the Privacy Act of 1974, as amended.

7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted invasion of personal privacy.

8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders or directives.

9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained.

10. To the National Archives and Records Administration for records management inspections conducted under 44 USC 2904 and 2906.

11. To the Office of Management and Budget when necessary to the review of private relief legislation.

STATE CODES (ABBREVIATIONS)

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia

American Samoa Trust Territory

AL

AK

AZ

AR

CA

CO

CT

DE

FL

GA

AS

TT

Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland

District of Columbia Virgin Islands

HI

ID

IL

IN

IA

KS

KY

LA

ME

MD

DC

VI

Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey

Guam

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

GU

New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina

Northern Marianas

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

CM

South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Puerto Rico

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

PR

PUBLIC BURDEN INFORMATION

Public burden reporting for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Reports and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send your completed form to this address.

Type of Investigation

Standard Form 85P (EG) Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

Form approved:

OMB No. 3206-0191

NSN 7540-01-317-7372

85-1602

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

A Extra Coverage

B Sensitivity/ Risk Level

C Date of Action

F Month Day Year

OPM

USE

ONLY

Codes Case Number

Agency Use Only (Complete items A through P using instructions provided by USOPM)

Geographic Location

G Position Code

H

OPAC-ALC

Number

N

SON

J

Name and Title

SOI

L

Accounting Data and/or Agency Case Number

O

Requesting Official

P Signature Telephone Number Date

Persons completing this form should begin with the questions below.

FULL

NAME

If you have only initials in your name, use them and state (IO).

If you have no middle name, enter "NMN".

- If you are a "Jr.," "Sr.," "II," etc., enter this in the box after your middle name.

DATE OF

BIRTH

Month Day YearLast Name First Name Middle Name Jr., II, etc.

PLACE OF BIRTH - Use the two letter code for the State. SOCIAL SECURITY NUMBER City County State Country (if not in the United States)

OTHER NAMES USED

Name Month/Year Month/Year

To#1 Name Month/Year Month/Year

To#2

Name Month/Year Month/Year

To#3 Name Month/Year Month/Year

To#4

Sex (Mark one box)

Female Male

CITIZENSHIP

Mark the box at the right that reflects your current citizenship status, and follow its instructions.

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. Answer items b and d.

I am a U.S. citizen, but I was NOT born in the U.S. Answer items b, c and d.

I am not a U.S. citizen. Answer items b and e.

Your Mother’s Maiden Name

UNITED STATES CITIZENSHIP If you are a U.S. Citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.

Naturalization Certificate (Where were you naturalized?)

Court City State Certificate Number Month/Day/Year Issued

Citizenship Certificate (Where was the certificate issued?)

City State Certificate Number Month/Day/Year Issued

State Department Form 240 - Report of Birth Abroad of a Citizen of the United States Give the date the form was prepared and give an explanation if needed.

Month/Day/Year Explanation

U.S. Passport

This may be either a current or previous U.S. Passport Passport Number Month/Day/Year Issued

DUAL CITIZENSHIP If you are (or were) a dual citizen of the United States and another country, provide the name of that country in the space to the right.

Country

ALIEN If you are an alien, provide the following information:

Place You Entered the United States:

City State Date You Entered U.S.

Month Day Year

Alien Registration Number Country(ies) of Citizenship

Compu/

ADP

D Nature of Action Code

E

Position Title

I

Location of Official Personnel Folder

K None

NPRC

At SON

Other Address ZIP Code

Location of Security Folder

M None At SOI

NPI

Other Address ZIP Code

OTHER

IDENTIFYING

INFORMATION

Height (feet and inches) Weight (pounds) Hair Color Eye Color

TELEPHONE

NUMBERS

Work (include Area Code and extension) Day Night ( )

Home (include Area Code) Day Night ( ) a b c d e

Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995.

Designed using Perform Pro, WHS/DIOR, Sep 95

WHERE YOU WENT TO SCHOOL

List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 7 years. List all College or University degrees and the dates they were received. If all of your education occurred more than 7 years ago, list your most recent education beyond high school, no matter when that education occurred.

Use one of the following codes in the "Code" block:

1 - High School 2 - College/University/Military College 3 - Vocational/Technical/Trade School

For schools you attended in the past 3 years, list a person who knew you at school (an instructor, student, etc.). Do not list people for education completely outside this 3-year period.

For correspondence schools and extension classes, provide the address where the records are maintained.

WHERE YOU HAVE LIVED

List the places where you have lived, beginning with the most recent (#1) and working back 7 years. All periods must be accounted for in your list. Be sure to indicate the actual physical location of your residence: do not use a post office box as an address, do not list a permanent address when you were actually living at a school address, etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas.

For any address in the last 5 years, list a person who knew you at that address, and who preferably still lives in that area (do not list people for residences completely outside this 5-year period, and do not list your spouse, former spouses, or other relatives). Also for addresses in the last 5 years, if the address is "General Delivery," a Rural or Star Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet.

Street AddressMonth/Year Month/Year

To#1 Apt. # City (Country) State ZIP Code

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knows You

CodeMonth/Year Month/Year

To#1 Degree/Diploma/Other Month/Year Awarded

Street Address and City (Country) of School State ZIP Code

Name of School

CodeMonth/Year Month/Year

To#2 Degree/Diploma/Other Month/Year Awarded

Street Address and City (Country) of School State ZIP Code

Name of School

CodeMonth/Year Month/Year

To#3 Degree/Diploma/Other Month/Year Awarded

Street Address and City (Country) of School State ZIP Code

Name of School

Enter your Social Security Number before going to the next page

Present

Street AddressMonth/Year Month/Year

To#2 Apt. # City (Country) State ZIP Code

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You

Street AddressMonth/Year Month/Year

To#3 Apt. # City (Country) State ZIP Code

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You

Street AddressMonth/Year Month/Year

To#4 Apt. # City (Country) State ZIP Code

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You

Street AddressMonth/Year Month/Year

To#5 Apt. # City (Country) State ZIP Code

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You

Telephone Number

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You Telephone Number

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You Telephone Number

Street Address Apt. # City (Country) State ZIP CodeName of Person Who Knew You Telephone Number

Telephone Number

Telephone Number

Telephone Number

Telephone Number

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

YOUR EMPLOYMENT ACTIVITIES

List your employment activities, beginning with the present (#1) and working back 7 years. You should list all full-time work, part-time work, military service, temporary military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 7-year period must be accounted for without breaks, but you need not list employments before your 16th birthday.

Code. Use one of the codes listed below to identify the type of employment:

CodeMonth/Year Month/Year

To#1 Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank

Present

1 - Active military duty stations 2 - National Guard/Reserve 3 - U.S.P.H.S. Commissioned Corps 4 - Other Federal employment

5 - State Government (Non-Federal employment) 6 - Self-employment (Include business and/or name of person who can verify)

7 - Unemployment (Include name of 9 - Other person who can verify) 8 - Federal Contractor (List Contractor, not Federal agency)

Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in your military duty locations or home ports.

Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.

Employer’s/Verifier’s Street Address

Street Address of Job Location (if different than Employer’s Address)

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

City (Country)

City (Country)

State

State

State

ZIP Code

ZIP Code

ZIP Code

Telephone Number

Telephone Number

Telephone Number

PREVIOUS

PERIODS

OF

ACTIVITY

(Block #1)

To

To

To

Position Title

Position Title

Position Title

Supervisor

Supervisor

Supervisor

#2

PREVIOUS

PERIODS

OF

ACTIVITY

(Block #2)

#3

PREVIOUS

PERIODS

OF

ACTIVITY

(Block #3)

Enter your Social Security Number before going to the next page

Code

To

Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank

Employer’s/Verifier’s Street Address

Street Address of Job Location (if different than Employer’s Address)

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

City (Country)

City (Country)

State

State

State

ZIP Code

ZIP Code

ZIP Code

Telephone Number

Telephone Number

Telephone Number

To

To

To

Position Title

Position Title

Position Title

Supervisor

Supervisor

Supervisor

Code

To

Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank

Employer’s/Verifier’s Street Address

Street Address of Job Location (if different than Employer’s Address)

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

City (Country)

City (Country)

State

State

State

ZIP Code

ZIP Code

ZIP Code

Telephone Number

Telephone Number

Telephone Number

To

To

To

Position Title

Position Title

Position Title

Supervisor

Supervisor

Supervisor

Month/Year Month/Year

Month/Year Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

Month/Year

#4

PREVIOUS

PERIODS

OF

ACTIVITY

(Block #4)

#5

PREVIOUS

PERIODS

OF

ACTIVITY

(Block #5)

#6

PREVIOUS

PERIODS

OF

ACTIVITY

(Block #6)

Enter your Social Security Number before going to the next page

YOUR EMPLOYMENT ACTIVITIES (CONTINUED)

Code

To

Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank

Employer’s/Verifier’s Street Address

Street Address of Job Location (if different than Employer’s Address)

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

City (Country)

City (Country)

State

State

State

ZIP Code

ZIP Code

ZIP Code

Telephone Number

Telephone Number

Telephone Number

To

To

To

Position Title

Position Title

Position Title

Supervisor

Supervisor

Supervisor

Code

To

Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank

Employer’s/Verifie…