RFQ ENCL CON ATTCH 4 - Request for PerSec Determination (Contractors).pdf

(Read the Privacy Act Statement prior to completing this form.)

U.S. SECURITIES AND EXCHANGE COMMISSION

100 F Street, N.E., Washington, DC 20549

REQUEST FOR PERSEC DETERMINATION (Contractors)

Section A: To Be Completed By the Applicant

1. Name (Last/Family) 2. First (Given) 3. Middle (or NMN) 4. Other Names Used 5. Suffix

6. Social Security Number 7. Date of Birth MM/DD/YYYY 8. Place of Birth (City and State) 9. Country

10. Gender

M F

15. Home Street Address 11. E-Mail Address (work) 12. E-Mail Address (personal)

13. Daytime Phone Number 14. Cell Phone Number

16. City 17. State 18. Zip Code 19. Position (Job) Title

20. US Citizen?

YYeses NoNoNo

21.Naturalized Citizen?

Yes No

Non-US Born Citizens Only: Complete 22-24 as applicable - must be US citizen for contracts that include IT services

22. Naturalization Certificate Number 23. Alien Registration Number 24. Country of Citizenship

25. IT Services Contract?

Yes No

Prior Federal Investigation Only: Complete 26-28

26. Agency 27. Level of Investigation 28. Date of Completion

Comments (A separate sheet of paper can be included for comments if additional space is needed)

Section B: To Be Completed By SEC Contract Officer Representative (COR)

1. Term of Service

Long Term Temporary less than 6 months

4. Company Name (Prime)

Name:

8. Contract Number

2. Office Assigned- IT services in any office must be US citizen 5. Company Name (Sub-Contractor, if applicable)

Name:

9. Contract End Date

3. Physical Office Location (select one)

ARO BRO CHRO DRO

FWRO LARO MIRO NYRO

PLRO SLRO SFRO HQ/OPC

6. Contract Program Manager

Name:

Phone:

10. SEC COR

Name:

Phone:

7. Other Contract Point of Contact (if applicable)

Name:

Phone:

11. Other SEC Point of Contact (if applicable)

Name:

Phone:

Section C: Notes

All documentation must be submitted by the COR to the Personnel Security mailbox at personnelsecurity@sec.gov.

1 of 2 v3. 06/2020

Attachment 4

PERSEC Data Form (v1. 06/2012)

REQUEST FOR PERSEC DETERMINATION (Employees)

REQUEST FOR PERSEC DETERMINATION (Contractors)

Privacy Act Statement The SEC is authorized to ask for this information under 5 CFR § 731 and 736, and Executive Order 13467. The authority for soliciting and verifying your SSN is Executive Order 9397.

The principal purpose of collecting this information is to assist SEC personnel in making an informed decision regarding suitability for a security clearance and to determine fitness for federal employment.

Disclosure of your SSN is voluntary. Failure to provide your SSN may delay processing and thereby delay a determination of suitability. Disclosure of all other personal information is voluntary. However, failure to provide the requested information may result in an adverse suitability determination. In addition to the disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, the information contained herein may specifically be disclosed: (1) to a Federal, State, or local law enforcement agency if the disclosing agency becomes aware of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal administrative proceeding if the Government is a party or in order to comply with a judge-issued subpoena; (3) To a Federal, State, or local agency, in response to its requests, in connection with the hiring or retention of an employee, the issuance of a security clearance, or the conduct of a security or background investigation of an individual, to the extent that the information is relevant and necessary to the requesting agency; (4) to the National Archives and Records Administration or the General Services Administration in records management inspections; (5) To the Office of Inspector General for investigating allegations of fraud or misconduct; (6) to a Member of Congress or a congressional office in response to an inquiry made on behalf of an individual who is the subject of the record; and (7) to SEC contractors or their authorized employees, and other Federal agencies, as necessary, for the purpose of assisting the SEC in the efficient administration of its programs. These contractors will be required to maintain Privacy Act safeguards with respect to such records. Disclosures may also be made in accordance with the Office of Personnel Management published system of records notice. (See OPM/Central-9).