OG3. PSQ Template 5 - Financial Responsibilities (20160712).pdf

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).

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 ________________

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).

Classify as Appropriate When Filled-in

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:

NOMINEE’S SIGNATURE_____________________________________

DATE_______________________