Attachment 9-DHS Form 11000-9 Fair Credit Reporting Act.pdf
PDF 55 KB Posted
- Attached to
- Training Support Services Federal contract opportunity
- Solicitation number
- 70LART25RPFB00006
About this file
This is DHS Form 11000-9 (07/2023), a disclosure and authorization form pertaining to consumer reports pursuant to the Fair Credit Reporting Act. The form authorizes the Department of Homeland Security to obtain consumer/credit reports for employment purposes, including evaluating an individual's fitness for employment, promotion, reassignment, retention, or access to classified and sensitive but unclassified information.
The form includes a Privacy Act Statement citing authority under the Homeland Security Act of 2002 and Executive Order 9397, along with disclosure terms indicating that providing information is voluntary but failure to do so may prevent fitness/suitability determinations. The form requires the individual's signature, date, and current organization assigned. This appears to be a standard template form that would be required as part of the contract's personnel security requirements for the FLETC Artesia Training Support Services opportunity.
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Text version
DEPARTMENT OF HOMELAND SECURITY
DISCLOSURE AND AUTHORIZATION
PERTAINING TO CONSUMER REPORTS
PURSUANT TO THE FAIR CREDIT REPORTING ACT
DHS Form 11000-9 (07/2023)
This is a release for the Department of Homeland Security to obtain one or more consumer/credit reports about you in connection with your application for employment or in the course of your employment with the Department. One or more reports about you may be obtained for employment purposes, including evaluating your fitness for employment, promotion, reassignment, retention, or access to classified information and/or sensitive, but unclassified information.
I, authorized the Department of Homeland Security to obtain such report(s) from any consumer/credit reporting agency for employment purposes. Copies of this authorization that show my signature are as valid as the original signed by me.
, hereby
Signature
Date
Current Organization Assigned
PRIVACY ACT STATEMENT
Authority: Homeland Security Act of 2002; 5 U.S.C. § 11001, “Enhanced Personnel Security Programs”; and Executive Order 9397, “Numbering System for Federal Accounts Relating to Individual Persons”.
Principle Purpose: To obtain consumer/credit reports in connection with an individual’s application for employment or ongoing employment with the DHS.
Routine Use(s): The information collected on this form may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary and authorized by the routine uses published in “DHS/ALL-023 Personnel Security Management System of Records”.
Disclosure: Providing this information is voluntary; however, failure to provide this information may prevent an individual's fitness or suitability determination for employment, promotion, reassignment, retention, and/or access to information.
PUBLIC BURDEN STATEMENT
In accordance with 5 C.F.R. 1320.3(h)(1), this information collection is exempt from the requirements of Public Law 104-13, "Paperwork Reduction Act of 1995".
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