OG3. PSQ Template 2 - Foreign Associations (20160712).pdf

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).

Classify as Appropriate When Filled-in

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:

NOMINEE’S SIGNATURE_____________________________________

DATE_________________