SIP_050515_eform.pdf

Security In-Processing (SIP) Form

PRIVACY ACT STATEMENT: Authority for collecting the requested information is contained in 50 U.S.C. § 401-441, Executive Order 10450, Executive Order 13526, Executive Order 12968, and ICD 704. DoD's Blanket Routine Uses (found at Appendix C of 32 CFR Part 310) apply to this information. Authority for requesting your Social Security Number (SSN) is Executive Order 9397, as amended. The requested information you provide will be used to confirm your identity in order to verify clearances and access. Your disclosure of the requested information is voluntary.

However, failure to furnish the requested information may delay or prevent the processing of your access request.

UImportant: Please answer each question to the best of your ability. Indicate “UNK” or “N/A” if appropriate.

Incomplete forms (areas left blank) will not be accepted and will cause delays in your processing.

Section 2: AFFILIATION (check one) – Please provide YOUR affiliation below.

Section 3: CITIZENSHIP Please provide YOUR citizenship information below.

Naturalization Certificate No:

Naturalization Certificate Date Issued: Place Issued:

Past Citizenships (if applicable, list here):

Page 1 of 2: Go to Page 2 to complete the Security Questionnaire

USecurity Questionnaire Important: If you answer yes to any of the following questions, provide a detailed answer in the comment box, including the dates.

1. Have you ever been a dual citizen of the U.S. and another country?

1.a. If yes, list the country:

2. Do you have any immediate family members (parents, full, step, or half siblings, spouse, in-laws, cohabitants, and/or fiancé (e)) who were not born in the U.S.? List all applicable family members, living or otherwise; on an Additional Contact Sheet (ACS), except U.S. citizens born abroad to U.S. parents (provide an explanation below).

3. Do you have anyone else living with you that was not born in the U.S.?

4. Other than those already listed, do you maintain a close and/or continuing association with anyone who was not born in the U.S.? (List all applicable associations on an ACS.)

5. List your most recent polygraph (when/where?)

6. Do you or your immediate family members have foreign property or other foreign financial interests?

7. Have you ever been involved in the loss or mishandling of classified information/material?

8. Have you been arrested and/or charged with a UCMJ violation since your last investigation?

9. In the last seven years, or since the age of 18, whichever is shorter, have you:

a. Had any alcohol-related arrests, treatment, or counseling?

b. Illegally used, possessed, bought, sold, or transferred any illegal drug or controlled substance?

c. Experienced financial difficulties that resulted in bankruptcy, repossession, tax lien, wage garnishment, judgment, or collection accounts?

10. In the last seven years, have you consulted with a healthcare professional regarding an emotional or mental health condition, or were you hospitalized for such a condition?

Indicate no if counseling was for:

- Marital, family, or grief not related to violence by you

- Counseling related to adjustments from service in a military combat environment

- You are a victim of sexual assault

11. In the last seven years, have you attended a language immersion course, studied abroad, or gone on personal travel outside of the United States?

If yes, please include dates of travel, city/country visited and the purpose of travel.

Your Signature: Date (MM/DD/YYYY):

Reviewed by SSO: Date (MM/DD/YYYY):

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(If a Civilian or Contractor)