Attachment 16 Standard Form 85P Questionnaire for Public Trust Positions.pdf

Standard Form 85P Revised December 2017 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved:

OMB No. 3206 0258

This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, public trust positions as defined in 5 CFR

731. 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 duties to be performed by an employee of a contractor are equivalent to the duties performed by an employee in a public trust position. For applicants, this form is to be used only after a conditional offer of employment has been made.

This form is not to be used for National Security sensitive positions.

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 public trust position or your ability to obtain or retain Federal or contract employment, 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 a public trust 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, or prosecution.

This form is a permanent document that may be used as the basis for future investigations, 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 85P questionnaires.

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.

Purpose of this Form

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.

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.

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.

Your Personal Interview

Background investigations for public trust 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 and your Declaration for Federal Employment (OF 306) 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 public trust position or your ability to obtain Federal or contract employment. To avoid such delays, you must request that the consumer reporting agencies lift the freeze in these instances.

In addition to the questions on this form, inquiry also is made about your adherence to security requirements your honesty and integrity, falsification, misrepresentation, and any other behavior, activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal.

After a suitability /fitness determination is made, you may also be subject to continuous vetting which may include periodic reinvestigations to ensure your continuing suitability for employment.

The Investigative Process

Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders, 13764, 10577, 13467, and 13488; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations (CFR), and Federal information processing standards.

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.

Your spouse's SSN is needed solely to allow the investigative service provider to make inquiries regarding whether there is relevant conduct on your part as a result of your relationship with your spouse. Your spouse is not subject of the investigation.

Authority to Request this Information

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 21, 25, and 27, however, neither your truthful responses nor information derived from those responses will be used as evidence against you in a subsequent criminal proceeding.

Note: If you complete the SF 85P, an Authorization for Release of Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) will be provided to you only in the event information arises in an investigation that requires further inquiry for resolution, and only to resolve such issues. This release authorizes an investigator to ask your health practitioner(s) only the questions specified on the release concerning mental health consultations of which the practitioner might be aware. If you are completing the SF 85P with the supplemental SF 85P-S, this release will be provided to you if you respond "yes" to the question regarding Your Medical Record. You may also be asked to complete a specific release if more detailed information is needed from your provider.

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Instructions for Completing this Form

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.

2. 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.

3. 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 drop down feature.

When entering a U.S. address or location, select the state or territory from the "States" drop down list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" drop down list and leave the "State" field blank.

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 this by checking the “Estimate” box.

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Final Determination on Your Suitability Final determination on your suitability for a public trust position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made. 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 making determinations of suitability for a public trust position.

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 and/or up to five (5) years imprisonment. In addition, Federal agencies generally fire, 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 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.

Disclosure Information The information you provide is for the purpose of investigating you for a 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.

Office of Personnel Management (OPM) Routine Uses The Privacy Act routine uses of agencies conducting or requesting investigations, or with authorized custody over your investigative information, commonly include some or all of the following:

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 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.

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d.

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.

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 appropriate 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.

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

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.

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.

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:

OPM, or any component thereof; or Any employee of OPM in his or her official capacity; or

Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or

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.

(1) (2)

(3)

(4)

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 5U.S.C. 1205 and 1206, or as may be authorized by law.

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-sector EEO complaint.

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.

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.

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.

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.

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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.

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.

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 counter terrorism officials to fulfill their responsibilities under applicable Federal law and policy, including but not limited to E.O. 12333, 13587and the National Insider Threat Policy and Minimum Standards.

To the appropriate Federal, State, local, tribal, foreign, or other public authority in the event of a natural or man made 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.

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.

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.

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Public Burden Information

Public burden reporting for this collection of information is estimated toaverage155minutesperresponse,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 OPM Forms Officer, U.S. Office of Personnel Management, Attn: OMB Number 3206-0258, 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number, 3206-0258, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Alabama AL Alaska AK Arizona AZ Arkansas AR California CA Colorado CO Connecticut CT Delaware DE District of Columbia DC Florida FL Georgia GA

Hawaii HI Idaho ID Illinois IL Indiana IN Iowa IA Kansas KS Kentucky KY Louisiana LA Maine ME Maryland MD

Massachusetts MA Michigan MI Minnesota MN Mississippi MS Missouri MO Montana MT Nebraska NE Nevada NV New Hampshire NH New Jersey NJ

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

South Dakota SD Tennessee TN Texas TX Utah UT Vermont VT Virginia VA Washington WA West Virginia WV Wisconsin WI Wyoming WY

American Samoa AS Baker Island FQ Guam GU Howland Island HQ Jarvis Island DQ

Johnson Atoll JQ Kingman Reef KQ Marshall Islands MH Micronesia, Federated States

FM

Midway Islands MQ Navassa Island BQ Northern Mariana Islands MP Palau PW

Palmyra Atoll LQ Puerto Rico PR Virgin Islands, United States

VI

Wake Island WQ APO/FPO America AA APO/FPO Europe AE APO/FPO Pacific AP

LOCATION CODES

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 Risk level 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

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.)

Estimated Permanent Relocation

Est. To (Month/Day/Year) e-OPF Other address/Web address of e-OPF

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

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), or removal and debarment from Federal Service.

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.

YES NO

Section 1 - Full Name 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.

Last Name First Name Middle Name Suffix

Section 4 - Social Security Number

Section 3 - Place of Birth Provide your place of birth.

City County Country (Required)State

Not applicable Provide your U.S. Social Security Number.

Section 2 - Date of Birth

Est.

Section 5 - Other Names Used

YES NO (If NO, proceed to Section 6)

Complete the following if you have responded 'Yes' to having used other names.

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.

Have you used any other names?

Provide your date of birth. (Month/Day/Year)

Middle nameFirst nameLast name

Provide the reason(s) why the name changedMaiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

#1

To (Month/Year)From (Month/Year)

Middle nameFirst nameLast name

Provide the reason(s) why the name changedMaiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

#2

From (Month/Year) To (Month/Year)

Middle nameFirst nameLast name

Provide the reason(s) why the name changedMaiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

#3

From (Month/Year) To (Month/Year)

Middle nameFirst nameLast name

Provide the reason(s) why the name changedMaiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

#4

From (Month/Year) To (Month/Year)

Sex

Section 6 - Your Identifying Information Provide your identifying information.

(inches)(feet)

Weight (in pounds) Hair color Eye color Female Male

Height

Enter your Social Security Number before going to the next page

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Section 7 - Your Contact Information

Home e-mail address Work e-mail address

Home telephone number Extension

International or DSN phone number

Work telephone number Extension

International or DSN phone number

Mobile/Cell telephone number Extension

International or DSN phone number

Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background investigation.

Day

Night

Both

Day

Night

Both

Day

Night

Both

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 Click HERE for U.S. State Department passport help http://travel.state.gov/passport Est.

Provide the name in which passport was first issued.

Middle nameLast name First name Suffix

Est.

(Month/Day/Year)(Month/Day/Year)Issue date Expiration date

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 name in which document was issued.

Middle nameLast name First name Suffix

Provide the name in which the certificate was issued.

Middle nameLast name First name Suffix

Were you born on a U.S. military installation?

YES NO (If NO, proceed to Section 10)

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.

Est.

Provide your citizenship certificate number.

Est.

Provide type of documentation of U.S. citizen born abroad.

FS 240 DS 1350 FS 545 Other (Provide explanation)

Provide the name of the base.

Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)

CountryStateCity

Provide the date the certificate was issued. (Month/Day/Year)

Provide the date the document was issued. (Month/Day/Year)

Enter your Social Security Number before going to the next page http://travel.state.gov/passport http://travel.state.gov/passport

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Provide the address of the court that issued the Certificate of Naturalization.

StateCity

Provide the name in which the Certificate of Naturalization was issued.

Middle nameLast name First name Suffix

Street Zip Code

Est.

Provide your Certificate of Naturalization number (N550 or N570).

(Provide explanation)

9.4 Complete the following if you answered that you are not a U.S. citizen.

Est.

Provide your residence status.

Est.

Provide your alien registration number (I-551, I-766)

Provide the name in which the document was issued.

Middle nameLast name First name Suffix

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)

Est.

StateCity

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 - utilize 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.

StateCity

Provide your 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 nameLast name First name Suffix

(Provide explanation)

Provide the basis of derived citizenship.

Other

By operation of law through my U.S. citizen parentEst.

(Month/Day/Year)

Est.

(Month/Day/Year)

Provide your date of entry in the U.S. (Month/Day/Year)

Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)

Provide the date document was issued

Provide the date of entry into the U.S.

(Month/Day/Year)

Provide document expiration date (I-766 ONLY)

Provide the date document was issued Provide document expiration date.

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

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.)

Est.

Present Est.

Do you currently hold citizenship with this country?

NOYES Provide explanation:

Entry #2

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. (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. (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

From Date (Month/Year) To Date (Month/Year)

Provide the date the passport (or identity card) was issued.

Provide the passport (or identity card) expiration date.

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.)

Est.

Present Est.

Do you currently hold citizenship with this country?

NOYES Provide explanation:

From Date (Month/Year) To Date (Month/Year)

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued)

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 the country in which 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. (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

Provide the date the passport (or identity card) was issued.

Provide the passport (or identity card) expiration date.

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Section 11 - Where You Have Lived

List the places where you have lived beginning with your present residence and working back 7 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 periods of residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for residence.

Entry #1

Est.

Present Est.

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code

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.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

Middle nameLast name First name Suffix

Provide your relationship to this person (Select 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

Enter residence information.

Est.

Provide date of last contact.

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)

Address APO or FPO APO/FPO State Code Zip Code Does the person who knew you have an APO/FPO address?(b)

YES

NO

YES

NO

To (Month/Year)From (Month/Year)

(Month/Year)

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Section 11 - Where You Have Lived - (Continued)

Entry #2

Enter residence information.

Est.

Present Est.

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code

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.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

Middle nameLast name First name Suffix

Provide your relationship to this person (Select 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

Est.

Provide date of last contact.

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)

Address APO or FPO APO/FPO State Code Zip Code Does the person who knew you have an APO/FPO address?(b)

YES

NO

YES

NO

To (Month/Year)From (Month/Year)

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Entry #3

Enter residence information.

Est.

Present Est.

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code

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.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

Middle nameLast name First name Suffix

Provide your relationship to this person (Select 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

Est.

Provide date of last contact.

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)

Address APO or FPO APO/FPO State Code Zip Code Does the person who knew you have an APO/FPO address?(b)

YES

NO

YES

NO

To (Month/Year)From (Month/Year)

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Enter residence information.

Entry #4

Est.

Present Est.

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code

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.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

Middle nameLast name First name Suffix

Provide your relationship to this person (Select 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

Est.

Provide date of last contact.

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)

Address APO or FPO APO/FPO State Code Zip Code Does the person who knew you have an APO/FPO address?(b)

YES

NO

YES

NO

To (Month/Year)From (Month/Year)

U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.

Entry #1

Section 12 - Where You Went to School

(a) Have you attended any schools in the last 7 years?

YES NO

(b) Have you received a degree or diploma more than 7 years ago?

YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)

Provide the dates of attendance.

Est.

Present

Est.

High School Vocational/Technical/Trade School

College/University/Military College Correspondence/Distance/Extension/Online School

Select the most appropriate below 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 CountryZip 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)

Day Night

Provide the name of the…