Exhibit 12 - GSA 176 Personal History.pdf

Federal Protective Service Expires: 10/01/2007

Statement of Personal History for Contract and Childcare Personnel

Form Receive Date :

NOTE : All contractor(s)/childcare personnel must complete all sections on form. If more space is needed for any item, continue under item 24. Failure to disclose any information may result in an unfavorable adjudication decision.

(See Privacy Act and Public Reporting Burden statements on page 4.)

1. SOCIAL SECURITY NUMBER 2. TELEPHONE NUMBER 3. DATE OF BIRTH

4. NAME DATA

(Give your full name.

Initials and abridgements are not acceptable)

10. COLOR HAIR

8. WEIGHT

9. COLOR EYES

7. HEIGHT

6. SEX

5. PLACE OF BIRTH (City/State, Cou ntry)

OTHER NAMES USED (Maiden name, names by former marriages, former name changed legally or otherwise, nicknames, etc. Specify which and show dates used.)

NAME (Last, first, middle)

MALE FEMALE

11. MARITAL STATUS

SINGLE WIDOW(ER)

DIVORCEDMARRIED

12. IF MARRIED, WIDOWED OR DIVORCED, GIVE FULL NAME AND DATE AND PLACE OF BIRTH

OF SPOUSE OR FORMER SPOUSE, AND DATE AND PLACE OF MARRIAGE. INCLUDING WIFE'S

MAIDEN NAME (Give same information regarding all previous marriages.)

13. RACE (Check one) A - Asian or Pacific, including Chinese, Japanese, Filipinos, Polynesians, Indonesians, and Asian Indians

B - Black

H - HispanicI - American Indian or Alaskan Native, including Eskimos

W - White

O - Other

14. DATES AND PLACES OF RESIDENCES ( If actual places of Residence differ from the Mailing addresses, furnish and identify both by placing "R" (for residence) or "M" (for mailing) in column "R/M". Begin with present and go back (10) years. Continue in Item 24 if necessary.)

R/M FROM TO NUMBER AND STREET CITY STATE ZIP CODE

15. CHECK

US CITIZEN

ALIEN

DERIVED

(Complete F)

NATURALIZED

(Complete A thru E )

BY BIRTH

A - CERT. NO. B - PETITION NO. C - DATE D - PLACE AND COURT

F - PARENT'S CERTIFICATION NUMBERSE - U.S. PASSPORT NUMBER

REGISTRATION NO. EXPIRATION DATE DATE OF ENTRY PORT OF ENTRY

FEDERAL PROTECTIVE SERVICE 176T FPS FORM ( REV. 10-04)

176T FPS FORM ( REV. 10-04) Page 2

16. EDUCATION ( All schools above elementary )

FROM TO

NAME OF SCHOOL ADDRESS YEAR FROM YEAR TO DEGREES

17. EMPLOYMENT ( List employment dates starting with your present employment for the last ten (10) years. Show ALL dates and addresses when unemployed. Give name under which employed if different from name now used. )

NAME OF EMPLOYER ( Firm or Agency) AND NAME OF SUPERVISOR

TYPE OF

WORK ADDRESS REASON FOR

LEAVING

18. HAVE YOU EVER BEEN DISMISSED OR FORCED

TO RESIGN FROM ANY POSITION FOR CAUSE ?

( If answer is "YES" furnish details in Item 22 )18a. MILITARY

SERVICE

(Past to Present)

HAVE YOU EVER BEEN IN VIOLATION OF MILITARY OFFENSE OF COURT MARTIAL OR DISCHARGED FROM THE

ARMED FORCES UNDER OTHER THAN HONORABLE CONDITIONS ?

YES NO

SERIAL NO. ( If none, give grade or rating at separation.)

BRANCH OF SERVICE

( Army, Navy, Air Force, etc.)

YEAR FROM YEAR TO

STATECITY

PHONE

NUMBER CITY STATE

( If answer is "YES" furnish details in Item 22 )YES NO

19. HAVE YOU EVER BEEN ARRESTED, CHARGED, OR HELD BY FEDERAL, STATE, OR OTHER LAW ENFORCEMENT AUTHORITIES FOR ANY VIOLATION OF ANY FEDERAL LAW, MILITARY LAW, STATE LAW, COUNTY LAW, MUNICIPLE LAW, RE GULATIONS, OR ORDINANCE ? ( Do not include traffic violations for which a fine of $25 or less was imposed. All other charges must be included even if they were dismissed.)

REASON CHARGED OR HELD DATE PLACE WHERE CHARGED OR HELD DISPOSITION

( If answer is "YES" give full details below )YES NO

FEDERAL PROTECTIVE SERVICE

176T FPS FORM ( REV. 10-04) Page 3

19a. HAVE YOU EVER BEEN CHARGED, ARRESTED OR HELD BY ANY LOCAL, STATE, OR FEDERAL LAW ENFORCEMENT AGENCY FOR ANY VIOLATION OR OFFENSE INVOLVING: CHECK YES/NO AS TO ARREST. FAILURE TO PROVIDE ARREST INFORMATION MAY RESULT IN AN UNFAVORABLE ADJUDICATION DECISION. ( If answer is "YES" give full details below )

RELATION

YEAR OF

BIRTH

REASON CHARGED OR HELD DATE PLACE WHERE CHARGED OR HELD DISPOSITION

20. RELATIVES ( Parents, spouse, divorced spouse, children, brothers, and sisters, living or dead. Name of spouse should include maiden name and any other names by previous marriage. If person is deceased, so state under "Address" and enter other information at time of death. )

NAME IN FULL COUNTRY

OF BIRTH

ADDRESS PRESENT

CITIZENSHIP

NAME ADDRESS YEARS KNOWN

21. REFERENCES ( Name three persons, not relatives or employers, who are well acquainted with you. )

Child

Sexual offender/registry

Domestic Violence

Yes No

Yes No

Yes No

PHONE

NUMBER

CITY STATE

CITY STATE

176T FPS FORM ( REV. 10-04) Page 4

22. SPACE FOR CONTINUING ANSWERS TO OTHER QUESTIONS ( Show item numbers to which answers apply. Attach a separate sheet if there is not enough space here. )

SIGNATURE

26.

CERTIFI-

CATION

23.

AUTHORI-

ZATION

AND

RELEASE

I hereby authorize the Department of Homeland Security to obtain any information required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Investigation Service (DIS), the U.S.

Office of Personnel Management (OPM), the Department of Homeland Security (DHS), (if applicable), and from the State Criminial History Repository (Childcare employees only) of each state where I have resided.

I have been notified of any employer's obligation to require a criminal history records check as a condition of employment and of my right to obtain a copy of the criminal history report by writing to the Department of Homeland Security, Freedom of Information Officer. I understand that I have a right to challenge the accuracy and competencies of any information contained in the report. I also understand that this information will be treated as privileged and confidential information. Case files are handled under the procedures for safeguarding records.

DATE

I declare under penalty of perjury that the statements made by me on this form are true, complete and correct.

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD

RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS.

Before signing this form, review it carefully to make sure you have answered all questions fully and correctly.

25. PUBLIC

REPORTING

BURDEN

STATEMENT

Public reporting burden for this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Security Division (PSS), Office of Federal Pro tective Service, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (3090-0006), Washington, DC 20503.

24. PRIVACY

ACT OF 1974

COMPLI -

ANCE IN -

FORMATION

Privacy Act of 1974 compliance information. Solicitation of information contained herein in authorized by Executive Order 10450, and/or Section 231 of the Crime Control Act of 1990 (42 U.S.C. 13041), and may be used as a basis for suitability determinations.

Your social security number is being requested pursuant to Executive Order 9397. Disclosure of the information by you is voluntary.

Information may be transferred as a routine use to appropriate federal, state, local, or foreign agencies when relevant to civil, criminal or regulatory investigation, prosecutions, or pursuant to a request by DHS or such other agency is in connection with the hiring or retention of an employee, the issuance of a license, grant, or other benefit. Information also may be transferred as a routine use to a duly authorized official engaged in an investigation or settlement of a grievance, complaint, or appeal filed by an employee. Failure to provide information requested on this form may result in the government's inability to determine your suitability for the position applied for or occupied, and may affect your prospects for employment or continued employment under a government contract, or at a federal facility, or with a government license.

I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

* This is a temporary form expires 10/1/07.