Attachment_L4_-_Personnel_Security_Questionnaire.pdf

Classify as appropriate when filled-in

Pre-Screening Questionnaire

Pre-Screening Security Questionnaire (PSQ), July 12, 2016

Privacy Sensitive – Any misuse or unauthorized disclosure may result in either civil or criminal penalties. Information 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 to the best of my knowledge:

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: Is any of your immediate family a citizen of a country other than the United States or do you or anyone in your immediate family claim dual citizenship? (Immediate family is a spouse, parent, sibling, child, cohabitant, step-parents, half- and step-siblings, and step-children of the subject.)

2) Foreign Associations:

Foreign Associations: Do you, your spouse or cohabitants have any continuing contact with citizens or dual citizens of a country other than the United States?

(Reporting is not required if contact with a foreign national only occurs while in the performance of official United States Government business.)

Foreign Assets: Do you, your spouse, and/or cohabitant have any financial interest or assets in a country other than the United States?

3) Other Than Official Government Foreign Travel: Have you visited any foreign countries since your last completed investigation?

4) Personal Conduct: Has your clearance or access been suspended, denied or revoked; or have you been arrested since your last completed investigation?

5) Financial Responsibility: 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?

PSQ TEMPLATE 1 - FOREIGN AFFECTIONS

PSQ Template 1 - Foreign Affections, July 12, 2016

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 or dual citizenship. One template must be completed for each foreign immediate family member. All foreign immediate family members 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? __ Yes __ No 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 ________

PSQ TEMPLATE 1 - FOREIGN AFFECTIONS

PSQ Template 1 - Foreign Affections, July 12, 2016

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).

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_________________________________________________________

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: _____________

Remarks:

NOMINEE’S SIGNATURE_____________________________________

DATE__________________

PSQ TEMPLATE 2 - FOREIGN ASSOCIATIONS

PSQ Template 2 - Foreign Associations, July 12, 2016

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).

To be completed if you, your spouse or cohabitant have any continuing contact with citizens of another country or dual citizens. One template must be completed for each foreign associate. All foreign associates must be listed even if previously reported. (Reporting is not required if contact with a foreign national only occurs while in the performance of official United States Government business.)

To be completed if you, your spouse, and/or cohabitant have any financial interest or assets in a country other than the United States? One template must be completed for each foreign interest or assets.

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. Country(ies) of Citizenship or Dual 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 ________

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).

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? ___________________ Balance? _____________ What is the purpose of the account? ________________________________________________

15. Do you, your spouse, or cohabitant own any foreign investment that is NOT traded on a U.S.

Exchange? __Yes __ No If yes, 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 __________________________________

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).

Remarks:

DATE_________________

PSQ TEMPLATE 3 - FOREIGN TRAVEL

PSQ Template 3 - Foreign Travel, July 12, 2016

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).

Report all non-official U.S. Government foreign travel since your last completed investigation. 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. 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 remark (e.g. "Many Short Trips").

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 U.S. 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 _________________________

PSQ TEMPLATE 3 - FOREIGN TRAVEL

PSQ Template 3 - Foreign Travel, July 12, 2016

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).

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: ____________________________________________________

Remarks:

DATE_________________________

PSQ TEMPLATE 4 – PERSONAL CONDUCT

PSQ Template 4 – Personal Conduct, July 12, 2016

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).

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:

a. Date of suspension _________________

b. Date of denial ___________________

c. 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

PSQ TEMPLATE 4 – PERSONAL CONDUCT

PSQ Template 4 – Personal Conduct, July 12, 2016

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).

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

Remarks:

DATE__________________________

PSQ TEMPLATE 5 – FINANCIAL RESPONSIBILITIES

PSQ Template 5 – Financial Responsibilities, July 12, 2016

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).

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 ________________

PSQ TEMPLATE 5 – FINANCIAL RESPONSIBILITIES

PSQ Template 5 – Financial Responsibilities, July 12, 2016

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).

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 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 ___________________

Remarks:

DATE_______________________