Section_L_-_Attachment_11_-_Pre-Screening_Questionnaire.pdf

Pre-Screening Questionnaire

Pre-Screening Questionnaire (PSQ), November 20, 2014

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulations (CFR).

Classify as Appropriate When Filled-in

Name: SSN: _____________________

City, State, and Country of Birth:

Date of Last Completed Investigation: _________________________________

I certify my answers on this questionnaire and attached templates are true, complete, and accurate:

Nominee’s Signature: Date:

For all “Yes” responses please provide supplemental information on the corresponding template PSQ Template 1 - Foreign Affections PSQ Template 2 - Foreign Associations PSQ Template 3 - Foreign Travel PSQ Template 4 - Personal Conduct PSQ Template 5 - Financial Responsibility

Questions (Y/N)

1) Foreign Affections: Are any of your immediate family members citizens of a country other than the US or do you or anyone in your immediate family claim dual citizenship? (Immediate family includes a subject’s spouse, parents, siblings, children, cohabitant, step-parents, half- and step-siblings, and step-children.)

2) Foreign Associations: Do you, your spouse or cohabitant have any close or continuing contact with citizens of another country; or any financial interests or assets in another country?

3) Foreign Travel: Other than official government foreign travel, have you visited any foreign countries not previously reported since your last completed investigation and not previously reported in an annual response to this question on this form? If so, please provide dates, countries, and reasons for travel.

4) Personal Conduct: Have you had your clearance suspended, denied, or revoked;

or have you been arrested since your last completed investigation? If yes, please explain.

5) Financial Responsibilities: Have you had any bills referred to a collection agency, had your wages garnished, have any tax liens against you or filed for bankruptcy since your last completed investigation? If yes, please explain.

J-Tech II

FA8240-15-R-7218

L–11 Attachment

PSQ TEMPLATE 1 - FOREIGN AFFECTIONS

PSQ Template 1 - Foreign Affections, November 20, 2014

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulations (CFR).

Classify as Appropriate When Filled-in

To be completed when the nominee has an immediate family member (spouse, cohabitant, parents, step-parents, sibling, step/half-sibling, child, or step-child) who claims foreign citizenship. One template must be completed for each foreign relation.

All foreign relations must be listed even if previously reported.

NOMINEE’S FULL NAME _____________________________ SSN _____________________

Are you a dual citizen of the United States and any other country? ___ No ___ Yes (If Yes list country________________)

Have you reported the information disclosed on this form to your local security officer? __ Yes __ No

If yes, date information was reported: __________________ Estimated? __ Yes __ No

FOREIGN RELATION INFORMATION

1. Name of Foreign National ____________________ 2. Country of Birth __________________________________________

3. Relationship to Nominee _____________________ 4. Country(ies) of Citizenship or dual Citizenship _________________

5. Current Address ________________________________________________________________________________________

6. Initial contact (date) and circumstances ______________________________________________________________________

7. Has this person visited you in the US? __ Yes __ No 8. Date of last visit to US ____________________________

9. Occupation (or if retired, previous occupation) ______________________________

10. Frequency of contact (check one) __ Daily __Weekly __ Monthly __ Annually __ Other (specify)_______________

11. Method of contact (all that apply) __ In-person __ E-mail __ Telephone __ Letters ___ Social Media __ Other

Explanation (if other method of contact applies): _______________________________________________________________

12. Has this person expressed any interest in your job? __ Yes __ No If yes, explain__________________________________

13. Is this person affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? __ Yes __ No __ Unknown

If yes, describe affiliation with foreign government, military, security, defense industry, foreign movement, or intelligence service _________________________________________________________________________________________________

14. Do you have any financial/material/emotional ties with this person? __ Yes __ No If yes, describe:

COMPLETE ONLY IF FOREIGN RELATION IS A SPOUSE OR COHABITANT

15. If spouse, date of marriage: _______________

16. If cohabitant, date cohabitation began: _____________

NOMINEE’S SIGNATURE_____________________________________ DATE__________________

J-Tech II

PSQ TEMPLATE 2 - FOREIGN ASSOCIATIONS

PSQ Template 2 - Foreign Associations, November 20, 2014

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulations (CFR).

Classify as Appropriate When Filled-in

To be completed if you, your spouse or cohabitant have any close or continuing contact with citizens of another country. One template must be completed for each foreign associate. All foreign associates must be listed even if previously reported.

NOMINEE’S FULL NAME _____________________________ SSN __________________________

Section 1 - Do you, your spouse, or cohabitant have foreign associations? ___ Yes ___ No (If yes, complete 1-12) Section 2 - Do you, your spouse, or cohabitant have foreign financial interests? ___ Yes ___ No (If yes, complete 13-17)

Have you reported the information disclosed on this form to your local security officer? __ Yes __ No

If yes, date information was reported:_______________ Estimated? __ Yes __ No

SECTION 1 - FOREIGN CONTACTS

1. Name of Foreign National _____________________________ 2. Citizenship _____________________________________

3. Country of Residence ________________________ 4. How long have you known this person? _______________________

5. Occupation (or if retired, previous occupation) _____________________ 6. Relationship to nominee ___________________

7. Frequency of contact (check one): __ Daily __ Weekly __ Monthly __Annually __ Other (Specify)_____________________

8. Method of contact (check all that apply): __ In-person __ E-mail __ Telephone __ Letters ___ Social Media __ Other

Explanation (if other method of contact applies): _______________________________________________________________

9. Type of contact (check all that apply): __ Acquaintance/Social/Casual __Friend __Business Associate __Extended Family __In-Laws __ Academic

10. Has this person expressed any interest in your job? __ Yes __ No If yes, explain__________________________________

11. Do you have any financial/material/emotional ties with this person? __ Yes __ No If yes, describe:

12. Is this person affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? __ Yes __ No __ Unknown If yes, describe affiliation: ________________________________________________

SECTION 2 - FOREIGN FINANCIAL INTERESTS

13. Do you, your spouse, or cohabitant own real estate in another country? __ Yes __ No If yes, provide the following:

In what country is the property?_______________________ What type of property?____________________________________

Date acquired_________________ Value of property_________________ How often do you visit? ______________________

Is there a co-owner? __ Yes __ No If yes, name and citizenship of the co-owner _______________________________________

What are your plans for the property (investment, retirement, etc.)?__________________________________________________

14. Do you, your spouse, or cohabitant have a foreign bank account __ Yes __ No If yes, provide the following information:

In what country is the bank account? ____________ What is the purpose of the account? _______________ Value? ________

15. Do you, your spouse, or cohabitant own any foreign investment that is NOT traded on a U.S. Exchange? __Yes __ No If yes, provide the name of the investment, its value, and who manages it ____________________________________________

16. Are there any special conditions required by the country for a foreign national to own property, maintain a bank account, or financial investment? __ Yes __ No If yes, provide conditions____________________________________________________

17. Would it be a financial hardship if you were to have to dispose of the property, bank account, or investment? __Yes __ No If yes, explain ____________________________________________________________________________________________

NOMINEE’S SIGNATURE_____________________________________ DATE____________

J-Tech II

PSQ TEMPLATE 3 - FOREIGN TRAVEL

PSQ Template 3 - Foreign Travel, November 20, 2014

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulations (CFR).

Classify as Appropriate When Filled-in

Report non-official U.S. Government foreign travel that has not been previously reported since your last investigation and not previously reported in an annual response to this question on this form. If you have lived near a border country and have made short (one day or less) trips to the neighboring country (e.g. Canada or Mexico), you do not need to list each trip .

Instead, provide the time period, the code, the country, and a note (“Many Short Trips”). If itinerary included more than one foreign country, list all countries visited. Do not list travel under official U.S. Government business, but you must include any personal trips to other countries made in conjunction with the official U.S. Government travel.

NOMINEE’S FULL NAME _____________________________ SSN ______________________

Have you reported the information disclosed on this form to your local security officer? __ Yes __ No

If yes, date information was reported:______________ Estimated? __ Yes __ No

Use these codes to indicate the purpose(s) of your visit:

1-Business/Professional (other than official US Government) 2-Volunteer activities 3-Education

4-Tourism 5-Visit family/friends 6-Trade show, conference, seminar 7-Other

Code ____ If other explain ___________

Date of Travel (month/year) _________________ Number of days ________________

Country/Countries & Cities: ______________________________________________________________________

1. Did you deviate from the itinerary you provided prior to your departure? ____ Yes ____ No If yes, explain

2. While traveling to, or in this country/countries, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when you entered or left this country? ____ Yes ____ No If yes, explain ________________________________________________________

3. While traveling to, or in this country/countries were you involved in any encounter with the police or did you experience any security issues? ___ Yes ___ No If yes, explain _________________________________________

4. While traveling to, or in this country/countries, were you contacted by, or in contact with, any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organization?

___ Yes ___ No If yes, explain __________________________________________________________________

5. While traveling to, or in this country/countries, were you contacted by, or in contact with, anyone exhibiting excessive knowledge of, or undue interest in, you or your job? ___ Yes __ No If yes, explain _________________

6. While traveling to, or in this country/countries, were you contacted by, or in contact with, anyone attempting to obtain classified information or unclassified, sensitive information (i.e., FOUO)? ___ Yes ___No If yes, explain

7. While traveling to, or in this country/countries, were you threatened, coerced, or pressured to cooperate with a foreign government official or foreign intelligence or security service? ___ Yes __ No If yes, explain:

NOMINEE’S SIGNATURE_____________________________________ DATE______________

J-Tech II

PSQ TEMPLATE 4 – PERSONAL CONDUCT

PSQ Template 4 – Personal Conduct, November 20, 2014

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of

Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulations (CFR).

Classify as Appropriate When Filled-in

NOMINEE’S FULL NAME __________________________ SSN: __________________________

Section 1 - Have you had your security clearance or access to classified information suspended, denied, or revoked since your last completed investigation? __ Yes __ No (If yes, answer questions 1-3)

Section 2 - Have you been arrested since your last completed investigation? __ Yes __ No (If yes, answer questions 4-11)

Have you reported the information disclosed on this form to your local security officer? __ Yes __ No

If yes, date information was reported: ______________ Estimated? __ Yes __ No

SECTION 1 - CLEARANCE RECORD

1. Provide the date your security clearance or access to classified information was suspended, denied, or revoked:

Date of suspension ________ Date of denial ________ Date of revocation ________

2. Provide the name of the agency that took this action: ________________________________________________

3. Provide an explanation of the circumstances that led to the suspension, denial, or revocation:________________

SECTION 2 - ARREST RECORD

4. Provide a description of the offense(s) you were arrested for: _________________________________________

5. Date of arrest: _____________ 6. Location of arrest:________________________________________

7. Did this arrest involve any of the following? (Check all that apply or select ‘No’) __ No

___ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, spouse, cohabitant, or former spouse

___ Firearms or explosives ___ Alcohol or drugs

8. If alcohol-related, were you ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol? __ Yes __ No

9. What is the disposition of this offense? ___________________________________________________________

10. Have you completed all of the court-ordered requirements of your sentencing? __ Yes __ No __ N/A

(If no, explain) _________________________________________________________________________________

11. If you received probation as part of your sentencing, provide dates: From _________ to __________ __N/A

NOMINEE’S SIGNATURE_____________________________________ DATE__________________

J-Tech II

PSQ TEMPLATE 5 – FINANCIAL RESPONSIBILITIES

PSQ Template 5 – Financial Responsibilities, November 20, 2014

Privacy Sensitive (when filled-in) – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information you provide is protected by the Privacy Act of 1974, U.S.C. Your responses to these questions are intended to aid security personnel in determining your eligibility to information protected under Executive Order 13526. The Department of Defense is authorized to ask these questions under Executive Orders 10450, 10865,12333, and 12968; sections 3301, 3302, and 9101 of Title 5, United States Code (U.S.C.); sections 2165 and 2201 of

Title 42, U.S.C.; chapter 23 of Title 50, U.S.C; and parts 2, 5, 731, 732, 736 of Title 5, Code of Federal Regulat ions (CFR).

Classify as Appropriate When Filled-in

NOMINEE’S FULL NAME ___________________________ SSN _________________________

Have you reported the information disclosed on this form to your local security officer? __ Yes __ No

If yes, date information was reported: _________________ Estimated? __ Yes __ No

SECTION 1 - BILL PAYMENT

Have you had any bills referred to a collection agency since your last completed investigation? __ Yes __ No

* If yes, answer questions 1-10

1. Type of account (credit card, utility bill, mortgage, medical, etc.) _________________________________________________

2. Name of account ____________________________________ 3. Amount in Dollars ______________

4. If property is involved, describe type (car, boat, house, etc.) ___________________________________

5. Did this issue result in property seizure/forfeiture? __ Yes __ No

6. Date financial issue began __________ 7. Date resolved __________ 8. What was the settlement amount? _____________

9. Describe circumstances that sent the account to collections ______________________________________________________

10. If financial issue not resolved, what is the current status and plan of repayment/resolution?____________________________

SECTION 2 - WAGE GARNISHMENT

Have you had your wages garnished since the date of your last completed investigation? __ Yes __ No

*If yes, answer questions 11-16

11. Garnishment for court ordered spousal/child support that did not involve delinquent payment on your part? ___ Yes ___ No

12. Describe circumstances that led to the garnishment ___________________________________________________________

13. Date garnishment began __________ 14. Date garnishment ends __________ 15. Amount _______

16. Payment Frequency _________

SECTION 3 - TAX LIENS

Have you had tax liens filed against you since the date of your last completed investigation? __ Yes __ No

* If yes, answer 17-24

17. Reason __ Failed to File __ Failed to Pay 18. Reason you failed to file and/or pay required tax _______________________

19. Provide the year(s) you failed to file and/or pay your Federal, State, or other taxes __________________________________

20. Agency owed tax _____________________ 21. Amount owed _____________ 22. Type of tax _____________________

23. Date tax lien resolved _________ 24. If not resolved, provide current status ________________________________________

SECTION 4 - BANKRUPTCY

Have you filed for bankruptcy since the date of your last completed investigation?__ Yes __ No *If yes, answer 25-33

25. Bankruptcy type __ Chapter 7 __ Chapter 11 __ Chapter 13 26. Date bankruptcy filed _________

27. Discharged? __ Yes __ No

28. Amount of bankruptcy ______________ 29. Name of court _________________ 30. Reason you filed ________________

31. If this is a Chapter 13 Bankruptcy, has the repayment plan been approved by the court ? __ Yes __ No

32. If this is a Chapter 13 Bankruptcy, provide terms and date of completion __________________________________________

33. If bankruptcy not yet resolved, (Chapter 7, 11, or 13), provide status _____________________________________________

NOMINEE’S SIGNATURE_____________________________________ DATE________________

J-Tech II