Attachment 3- SOW- Person Model PII Sheet.doc

Person Model pii sheet

The USDA Point of Contact (POC) for one of your organization’s Federal government contracts, grants or agreements has determined by USDA Credential Matrix that a performing non-employee requires a LincPass. The information collected on this Personal Identity Information (PII) sheet is required for LincPass sponsorship. This information is to be collected and transmitted in accordance with The Privacy Act of 1974. For details on the Privacy Act of 1974, visit this website: http://www.usdoj.gov/oip/privstat.htm.

Instructions: Enter the information below for the non-employee LincPass applicant. An asterisk (*) indicate a required fields.

Company/Organization Name (where applicable)

*Sponsor/USDA POC Name

Existing Background Investigation? Yes/No/Don’t Know. If yes, enter the agency that conducted the investigation (e.g. USDA, Treasury, Energy, etc.).

*Name: Enter applicant's complete name as it appears on their government-issued ID (e.g. driver’s license or passport). If the information doesn’t match, the non-employee will encounter problems during enrollment and may have to reapply.

*Date of Birth (mm/dd/yyyy)

Place of Birth: City/State. If outside U.S., enter City/Country.

Gender

*Social Security Number

*Country of Citizenship

Federal Emergency Response Official: Yes/No. If yes, explain the applicant’s designation, e.g., “Continuity Coordinator.”

Note: This only applies to an Agency-identified person serving in an Emergency Response Official capacity. Contact your Security Officer for more information.

*Home Address: Enter the full address as it appears on the applicant’s government-issued ID.

Phone/Type (e.g. Business)

*Email Address (business email preferred) Required for enrollment notification. If the applicant does not have a business email address, enter the address of the person who will manage enrollment activities, e.g. Security Officer or Supervisor.

Please hand carry or send via locally-secured fax to:

[Enter Security Officer/Data Entry Personnel Contact Information]