Attachment M - SF-85 FBI LAR Form.pdf

Standard Form 85 Revised December 2013 U.S. Office of Personnel Management 5 CFR Parts 731 and 736

Form approved:

OMB No. 3206-0261

Questionnaire for Non-Sensitive Positions

Follow instructions fully or we cannot process your fonn. Be sure to sign and date the certification statement on Page 5 and the release on Page 6. If you have any questions, call the office that gave you the fonn.

Purpose of this Form

The U.S. Government conducts background investigations to establish that applicants or incumbents either employcd by the Government or working for the Government under contract, arc suitable for the job.

Infonnalion from this fonn is used primarily as the basis for this investigation. Complete this fonn only after a conditional offer of employment has been made.

Giving us the infonnation 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 infonnation we request. This may affcct your placement or employment prospects.

Authority to Request this Information

The U.S. Government is authorized to ask for this infonnation under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code;

and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.

Your Social Security Number is needed to keep records accurate, bccause 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 arc conducted using your responses on this fonn and on your Declaration for Federal Employment (OF 306) to develop infonnation to show whether you are reliable, trustworthy, and of good conduct and character. Your currcnt cmployer must be contacted as part of the investigation, even if you have prcviously indicated on applications or other fonns that you do not want this.

Instructions for Completing this Form

I. Follow the instructions given to you by the person who gave you the fonn and any other clarifYing instructions furnished by that person to assist you in completion of the fonn. Find out how many copies of the form you arc to tum 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 fonn is not legible, it will not be accepted). You may also be asked to submit your fonn in an approvcd electronic fonnat.

3. All questions on this fonn must be answered. If no response is necessary or applicable, indicate this on the fonn (for example, enter "Nonc" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to thc best of your ability and indicate this by marking "APPROX." or "EST."

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

5. You must usc the State codes (abbreviations) listed on the back of this page when you fill out this fonn. 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 Conn will assist you in completing the ZIP codes.

7. All telephone numbers must include area codes.

8. All dates provided on this fonn must be in MonthlDayN ear or Month/Year fonnat. Use numbers (1-12) to indicate months. For example, June 10, 1978, should be shown as 6110178.

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 Uniled States.

10. If you need additional space to list your residences or employmentslself-employmentslunemployment 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 usc must contain your name and Social Security Number at the top of the page.

Final Determination on Your Eligibility

Final detennination on your eligibility for a position 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 infonnation before a final decision is made.

Penalties for Inaccurate or False Statements

The U.S. Criminal Codc (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, andlor 5 years imprisonment, or both. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these fonns, and this remains a part of the pennanent record for future placements. Your trustworthiness is a very important consideration in deciding your suitability. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any infonnation you give us on the form and to make your comments part of the record.

Disclosure ofInformation

The information you give us is for the purpose of determining your suitability for Federal employment; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative infonnation is governed by thc Privacy Act. The agency which requested the investigation and the agency which conducted the investigation have published notices in the Federal Register describing the systems 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 fonn, and infonnation we collect during an investigation may be disclosed without your consent as pennitted by the Privacy Act (5 USC 552a(b»)and as follows:

PRIVACY ACT ROUTINE USES

1. To the Departmentof 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 representthe 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 Govemment 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 14. 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 enforcingor implementing the statute. rule, regulation, or order.

4. To any source or potential source from which information is requested in the COurseof an investigationconceming 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 offICewithin 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 tIlis 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 govemments. 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 Attomey General and promulgat,ed 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 Califomia Colorado Connecticut Delaware Florida Georgia

AL Hawaii HI Massachusetts MA New Mexico NM South Dakota SDAK Idaho 10 Michigan MI New York NY Tennessee TN AZ Illinois IL Minnesota MN North Carolina NC Texas TX AR Indiana IN Mississippi MS North Dakota NO Utah UT CA Iowa IA Missouri MO Ohio OH Vermont VT CO Kansas KS Montana MT Oklahoma OK Virginia VA CT Kentucky KY Nebraska NE Oregon OR washington WA DE Louisiana LA Nevada NV Pennsylvania PA West Virginia WV FL Maine ME New Hampshire NH Rhode Island RI Wisconsin WI GA Maryland MD New Jersey NJ South Carolina SC Wyoming WY

AS District of Columbia DC Guam GU Northern Marianas CM Puerto Rico PR IT Virgin Islands VI

American Samoa Trust Territory

PUBLIC BURDEN INFORMATION

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instrudions.

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the colledion 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.

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

QUESTIONNAIRE FOR

NON-SENSITIVE POSITIONS

Form approved:

OMS No. 3201)..0281

Codes Case Number

E Geographic Location

IIPAC J Accounting Data and/or Agency Case Number

F Position ntle

G

SON

H SOl

KRequesting Name and TIlle Official

Signature Telephone Number Date

.FULL elf you have only initials in your name, use them and state (10).

NAME elf you have no middle name, enter "NMN".

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

oDATE OF

BIRTH

~OTHER NAMES USED

••••. Give other names you used and the periodof time you used them (for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(s)). If the other name Is your maiden name, put "nee" in front of it.

YearLast Name First Name Middle Name

.PLACE OF BIRTH - Use the two letter code for the State.

City County

Name MonthlYear MonthlYear Name MonthlYear MonthlYear

To To #1 #3

MonthlYear MonthlYear

To

Name #2

MonthlYear MonthlYear

• SEX (Mark one box)

To

Name #4

Female Male

CITIZENSHIP

e Mark the box at the right that reflects your currentcitizenship status, and follow its instructions.

• Your Mother's Maiden NameI 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)

Iam not a U.S. citizen. (Answer items b and e) m in the U.S., provide information about one or more of the following proofs of your citizenship.

IState I Certificate Number IMonthlDaylYear Issued

Citizenship Certificate (Where was the certificate issued?)

City IState I Certificate Number I Month/DaylYear Issued

State DepartmentFonn 240 - Report of Birth Abroad of a Citizen of the United States Give the date the fonn was MonlhlDaylYear Explanation prepared and give an explanation if needed U.S. Passport

ThiSmay be either a current or previous U.S. Passport Passport Number Month/OaylYear Issued

«D DUAL CI11ZENSHIP CountryIf you are (or were) a dual citizen of the United States and I another country, provide the name of that country in the space to the right.

.WHERE YOU HAVE LIVED

List the places where you have lived, beginning with the most recent (#1) and working back 5 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 duly locatiOns under 90 days (list your permanent address instead), and you Should use your APOfFPO address if you lived overseas.

For any address in the last 3 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 3-year period, and do not list your spouse, former spouses, or other relatives).

MonthlYear MonthfYear Street Address Apt. # City (Country) State ZIP Code#1 To Present _..._v, _,..:1' ••.•.••• , ''''''" •••.•...,. TUU uu=,~uu, ••"" ApI. IF "''Y'll.,;oumry) :Slate ZIP Code

MonthlYear MonthlYear Street Address Apt. # City (Country) State ZIP Code #2 To Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code

MonthlYear MonthlYear Street Address Apt. # City (Country) State ZIP Code#3 To Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code

MonthlYear MonthlYear Street Address Apt. # City (Country) State ZIP Code#4 To Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code

MonthlYear MonthlYear Street Address Apt. # City (Country) State ZIP Code#5 To Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code

.WHERE YOU WENT TO SCHOOL

List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and wortclng back 5 years. List all College or University degrees and the dates they were receiVed. II all of your education occurred more than 5 years ago, list your most recent education beyond high school, no matter when that education oocurred.

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

1- High School 2 - ColiegefUniversityfMilitary College 3 - VocationalfTechnicalfTrade School

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

#1 MonthlYear MonthlYear

To

Name of School DegreefDiplomafOther onthlYear Awarded

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

#2 To

Name of School Degree/Diploma/Other MonthfYear AwardedMonthlYear MonthlYear treet Address and City (Country) of School State ZIP Code

#3 To

Name of School Degree/DiplomafOther

ZIP Code

MonthlYear MonthlYear MonthfYear Awarded

Street Address and City (Country) of School State

YOUR EMPLOYMENT ACTIVITIES

List your employmentac!ivities, beginning with the present (#1) and working back 5 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 5-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 1 - Active military duty stations 5 - State Govemment (Non-Federal 7 - Unemployment (Include name of 9 - Other2 - National Guard/Reserve employment) person who can verify) 3 - U.S.P.H.S. Commissioned Corps 6 - Self-employment {Include bUSiness name 8 - Federal Contractor (List Contractor, 4 - Other Federal employment andlor name of person who can verify) not Federal agency)

• EmployerNerifier 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 conceming 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.

MonthlYear MonthlYear ICode EmployerNerifier NamelMilitary Duty Location Your Position TitlelMilitary Rank #1 To Present Employer'sNerifier's Street Address City (Country) Slate ZIP Code Telephone Number

Street Address of Job location (if different than Employer's Address) City (Country) State ZIP Code Telephone Number

Supervisor's Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number

MonuI'.ear MonUIITear •.•OSIDonIllIe Supervisor

PREVIOUS To PERIODS MonthlYear MonthlYear Position 'Tille SupervisorOF ACTIVITY To (Block #1) MonthlYear MonthlYear Position 'Tille Supervisor

To MonthlYear MonthlYear ICode EmployerNerifier NamelMilitary Duty location Your Position TitlelMililary Rank

#2 To Employer'sNerilier's Street Address City (Country) State ZIP Code Telephone Number

Street Address of Job Location (if different than Employer's Address) City (Country) State ZIP Code Telephone Number

Supervisor's Name & Street Address (if different than Job Location) City (Country) State ZIP Gode Telephone Number

MonthlYear MonthlYear Position 'Tille Supervisor

PREVIOUS To PERIODS MonthlYear MonthlYear POSition 'Title Supervisor

OF

ToACTIVITY

(Block #2) MonthlYear MonthlYear Position 'Tille Supervisor To

MonthlYear MonthlYear ICode EmployerNerifier NamelMililary Duty Location Your Position TitlelMililary Rank #3 To Employer'sNerifier's Street Address City (Country) State ZIP Code Telephone Number

Street Address of Job Location (if different than Employer's Address) City (Country) State ZIP Code Telephone Number

Supervisor's Name & Street Address (if different than Job location) City (Country) State ZIP Code Telephone Number

MonthlYear MonthlYear POSition'Title Supervisor

PREVIOUS To PERIODS MonthlYear MonthlYear Position 'Tille Supervisor

OF

ACTIVITY To (Block#3) MonthlYear MonthlYear Position 'Tille Supervisor

YOUR EMPLOYMENT ACTIVITIES (CONTINUED)

MonthlYear MonthNear ICode EmployerNerilier NamelMilitary Duty Location Your Position TitJeJMilitary Rank#4 To

Emptoyer'slVerifier's Street Address City (Country) Slate ZIP Code Telephone Number

Street Address of Job Location (if different than Employer's Address) City (Country) State ZIP Code Telephone Number

Supervisor's Name & Street Address (if ditrerent than Job Location) City (Country) State ZIP Code Telephone Number

MonthNear MonthNear Position nile Supervisor

PREVIOUS To PERIODS MonthNear MonthNear Position nile SupervisorOF ACTIVITY To (Block 114) MonthNear MonthNear Position nile Supervisor

To MonthNear MonthlYear ICode EmployerNerilier NameJMilitary Duty Location Your Position TitleJMilitary Rank#5 To

Employer'sNerilier's Street Address City (Country) State ZIP Code Telephone Number

Street Address of Job Location (if different than Employer's Address) City (Country) State ZIP Code Telephone Number

Supervisor's Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number

MonthNear MonthNear Positlon Title Supervisor PREVIOUS To PERIODS MonthNear MonthNear Position Title SupervisorOF ACTIVITY To (Block #5) MonthlYear MonthNear Position Title Supervisor

To MonthNear MonthNear I Code EmployerNerilier NamelMililary Duty Location Your Position TiUeIMilitary Rank

#6 To Employer'sNerifier's Street Address City (Country) State ZIP Code Telephone Number

Street Address of Job Location (if ditrerent than Employer's Address) City (Country) State ZIP Code Telephone Number

Supervisor's Name & Street Address (if different than Job location) City (Country) State ZIP Code Telephone Number

MonthNear MonthNear PositionntJe Supervisor

PREVIOUS To I>ERIODS MonthNear MonthNear Position ntle SupervisorOF ACTIVITY To (Block #6) MonthNear MonlhlYear POSitionTille Supervisor

To

_ PEOPLE WHO KNOW YOU WEU

List three people who know you well and live In the United States, They shOUldbe good friends, peers, colleagues, college roommates, etc., whose combined association with you covers as well as possible the last 5 years, 00 not list your spouse, former Spouses, or other relatives, and try not to list anyone who is listed elsewhere on this form.

Name #1

Page4

Home or Work Address

Dates Known MonthNear MonthNear

To

Name #2 Home or Work Address

Name #3 Home or Work Address

EnteryourSocialSecurityNumberbeforegOingto thenextpage---------- __ +

_ YOUR SELECTIVE SERVICE RECORD Ves Noe Are you a male born after December 31, 1959? If "No," go to 13. If "Yes," go to b.

G) Have you registered with the Selective Service System? If ''Yes,'' provide your registration number. If "No," show the reason for your legal exemption below.

Registration Number Legal Exemption Explanation

I

• YOUR MILITARY HISTORY Yes No

E) Have you served in the United States military?

~ Have you served in the United States Merchant Marine?

List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service (#1) and work backward. If you had a break in service, each separate period should be listed.

Code, Use one ofthe codes listed below to identify your branch of service:

1 - Air Force 2 - Army 3 - Navy 4 - Marine Corps 5 - Coast Guard 6 - Merchant Marine 7 _National Guard

OlE, Mark "0" block for Officer or "E" block for Enlisted.

Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an "X": use the two.letter code for the state to mark the block.

Country. If your service was with other than the U.S. Armed Forces. identify the country for which you served.

To

E Status Country MonthlYear MonthlYear Code o

Active Inactive Reserve Reserve

Nalional Guard (SIBle)

Service/Certificate #

Active

To

ILLEGAL DRUGS Yes No

In the last year, have you used, possessed. supplied. or manufactured illegal drugs? When used Without a prescription. illegal drugs include marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaqualone, tranqUilizers, etc.), hallucinogenics (LSD, PCP, etc.). (NOTE: Neither your truthful response nor information derived from your response will be used as evidence against you in any subsequent criminal proceeding.)

If you answered ''Yes,'' provide information relating to the types of substance(s). the nature of the activity, and any other details relating to your involvement with illegal drugs. Include any treatment or counseling received.

To

MonthlYear MonthlYear Type of Substance Explanation

To

Continuation Space

TO

Use the continuation sheet(s) (SF86A) for add~ional answers to items 8, 9, and 10. Use the space below to continue answers to all other items and any information you would liKe to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your name and Social Security number. Before each answer.

identify the number of the item.

After completing this form you should review your answers to all questions to make sure the form is complete and accurat.e. and then sign and date the following certification and sign and date the release on Page 6.

Certification That My Answers Are True

My statements on this fonn. and any attachments to it. are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See section 1001 oftille 18, United States Code).

Signature (Sign in ink) I Date

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

Form Approved OMB No. 3206-0261

QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release infonnation about you, then sign and date it in ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation or reinvestigation to obtain any infonnation relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of infonnation to include publically available electronic infonnation. This infonnation may include, but is not limited to, my academic, residential, achievement, perfonnance, attendance, disciplinary, employment history, and criminal history record infonnation.

I understand that, for some sources of infonnation, a separate specific release will be needed, and I may be contacted for such a release at a later date.

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with infonnation in SSA records and provide the results of the match) to the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide explanatory infonnation to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.

I Authorize custodians of records and other sources of infonnation pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

J Understand that the infonnation released by records custodians and sources of infonnation is for official use by the Federal Government only for the purposes provided in this Standard Fonn 85, and that it may be disclosed by the Government only as authorized by law.

Photocopies of this authorization with my' signature are valid. This authorization is valid for two (2) years from the date signed.

Signature (Sign in ink) I Full name (Type or print legibly) Date signed (mm/dd/yyyy)

Other names used Social Security Number

Current street address Apt. # City (Country) State ZIP Code Home telephone number