f1600-07 - Background Questionnaire for Contractors.pdf

Page 1 of 3FDIC 1600/07 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028

Email Forms@fdic.gov with any questions or difficulties using this form.

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTORS

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820(a), 1822(f); Executive Order 9397 as amended; and 12 C.F.R. Part 366. The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C.

20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Page down to access form 1600/07 mailto:Forms@fdic.gov http://www.fdic.gov/about/privacy mailto:Privacy@fdic.gov

Page 2 of 3FDIC 1600/07 (6-21)

Expiration Date: 06/30/2028

Email Forms@fdic.gov with any questions or difficulties using this form.

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTORS

INSTRUCTIONS: This form is to be completed by companies that wish to become contractors for the FDIC. Complete each item as it applies to your firm.

SECTION I - CONTRACTOR INFORMATION

1. Name of Contractor (Do not use acronyms unless applicable.) 2. Federal Tax ID Number

3. Trade Name (If different from contractor name.)

4. Type of Business

5. Street Address (Include City, State, and Zip Code.) 6. Email Address

7. Solicitation/Contract Number (If applicable.) 8. Contact Name 9. Telephone

SECTION II - JOINT VENTURE ENTITIES (IF APPLICABLE)

10. Complete the following.

JOINT VENTURE

Name of Joint Venture Federal Tax ID Number

Street Address (Include City, State, and Zip Code.)

Contact Name Telephone

JOINT VENTURE

Name of Joint Venture Federal Tax ID Number

Street Address (Include City, State, and Zip Code.)

Contact Name Telephone

JOINT VENTURE

Name of Joint Venture Federal Tax ID Number

Street Address (Include City, State, and Zip Code.)

Contact Name Telephone mailto:Forms@fdic.gov

Page 3 of 3FDIC 1600/07 (6-21)

Expiration Date: 06/30/2028

Email Forms@fdic.gov with any questions or difficulties using this form.

JOINT VENTURE

Name of Joint Venture Federal Tax ID Number

Street Address (Include City, State, and Zip Code.)

Contact Name Telephone

JOINT VENTURE

Name of Joint Venture Federal Tax ID Number

Street Address (Include City, State, and Zip Code.)

Contact Name Telephone

SECTION III - CERTIFICATION AND AUTHORIZATION

Select this box if information on additional entities has been attached to this form.

I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information and the information provided to the FDIC regarding contracting with the FDIC in order to verify the contractor's fitness and integrity to provide services to or on behalf of the Federal Deposit Insurance Corporation. The background investigation I am authorizing may require information contained herein and acquired during the investigation to be disclosed to third parties, including credit-reporting businesses and State and local licensing agencies. I hereby authorize and give my consent to such disclosures.

NOTE: Management official means any shareholder, employee, or partner who controls a company and any individual who directs the day-to-day operations of a company. With respect to a partnership whose management committee or executive committee has responsibility for the day-to-day operations of the partnership, management official means only a member of such committee but, if no such committee exists, management official means each of the general partners. (12 U.S.C. § 366.2(I))

11. Name of Management Official Completing Form (Type or print.) 12. Title

13. Signature (Sign in ink.) 14. Date mailto:Forms@fdic.gov

FDIC 1600/07 (6-21)

FDIC 1600/07 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028 Email Forms@fdic.gov with any questions or difficulties using this form.

Email Forms@fdic.gov with any questions or difficulties using this form.

FDIC 1600/07 (6-21)

FDIC 1600/07 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028 Email Forms@fdic.gov with any questions or difficulties using this form.

Email Forms@fdic.gov with any questions or difficulties using this form.

FDIC 1600/07 (6-21)

FDIC 1600/07 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028 Email Forms@fdic.gov with any questions or difficulties using this form.

Email Forms@fdic.gov with any questions or difficulties using this form.

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTORS

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTORS

PRIVACY ACT STATEMENT

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820(a), 1822(f); Executive Order 9397 as amended; and 12 C.F.R. Part 366. The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820(a), 1822(f); Executive Order 9397 as amended; and 12 C.F.R. Part 366. The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

ESTIMATED REPORTING BURDEN

PRIVACY ACT STATEMENT

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Page down to access form 1600/07 Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Page down to access form 1600/07 Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTORS

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTORS

INSTRUCTIONS: This form is to be completed by companies that wish to become contractors for the FDIC. Complete each item as it applies to your firm.

INSTRUCTIONS: This form is to be completed by companies that wish to become contractors for the FDIC. Complete each item as it applies to your firm.

SECTION I - CONTRACTOR INFORMATION

SECTION 1 - CONTRACTOR INFORMATION

SECTION II - JOINT VENTURE ENTITIES (IF APPLICABLE)

SECTION 2 - JOINT VENTURE ENTITIES (IF APPLICABLE)

10. Complete the following.

10. Complete the following.

SECTION III - CERTIFICATION AND AUTHORIZATION

SECTION 3 - CERTIFICATION AND AUTHORIZATION

I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information and the information provided to the FDIC regarding contracting with the FDIC in order to verify the contractor's fitness and integrity to provide services to or on behalf of the Federal Deposit Insurance Corporation. The background investigation I am authorizing may require information contained herein and acquired during the investigation to be disclosed to third parties, including credit-reporting businesses and State and local licensing agencies. I hereby authorize and give my consent to such disclosures.

NOTE: Management official means any shareholder, employee, or partner who controls a company and any individual who directs the day-to-day operations of a company. With respect to a partnership whose management committee or executive committee has responsibility for the day-to-day operations of the partnership, management official means only a member of such committee but, if no such committee exists, management official means each of the general partners. (12 U.S.C. § 366.2(I)) I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information and the information provided to the FDIC regarding contracting with the FDIC in order to verify the contractor's fitness and integrity to provide services to or on behalf of the Federal Deposit Insurance Corporation. The background investigation I am authorizing may require information contained herein and acquired during the investigation to be disclosed to third parties, including credit-reporting businesses and State and local licensing agencies. I hereby authorize and give my consent to such disclosures.

NOTE: Management official means any shareholder, employee, or partner who controls a company and any individual who directs the day-to-day operations of a company. With respect to a partnership whose management committee or executive committee has responsibility for the day-to-day operations of the partnership, management official means only a member of such committee but, if no such committee exists, management official means each of the general partners. (12 U.S.C. § 366.2(I))

FDIC

1600/07 Background Investigation Questionnaire for Contractors Todd Hamme 1/24/2017

DOA/SEPS

For questions regarding form, email Forms@fdic.gov.

6-3-2021 (AH)