Section J 2C Form CSO-005 Preliminary Background Check Form.pdf

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Form CSO-005 Rev. 11/21 Page of

UNCLASSIFIED // FOUO

Note: Completed forms containing PII must be encrypted and include the appropriate marking (U/FOUO) in the SUBJECT line of the message prior to dissemination via email outside of USMS.

UNCLASSIFIED // FOUO

U.S. Department of Justice United States Marshals Service Preliminary Background Check Form OMB Control No. 1105-0105 - Exp. 10/31/2024

INSTRUCTIONS FOR CONTRACTING COMPANY TO COMPLETE THIS FORM

This form must be used and completed by the contractor only, unless otherwise noted, to conduct preliminary background checks on those individuals proposed to perform on your company's behalf under the United States Marshals Service's contract for court security services. Incomplete forms or illegible forms will be considered unacceptable and will be returned. This form must be submitted in accordance with the time requirements stated in the applicable United State Marshals Service's contract.

PART I

PART II

4. Preferred Title (Check one):

6. Social Security Number:

9. Is the applicant a citizen of the United States of America?

If Naturalization citizen:

10. Did the applicant graduate from high school or have a GED high school equivalency?

If 'Yes', answer questions below:

11. Can the applicant read, write and speak the English language?

12. Does the applicant have a current U.S. driver's license?

12b. If yes, has the applicant maintained a safe driving record for the past five (5) years?

12c. If no, can the applicant obtain a valid U.S. driver's license?

13. Did the applicant complete or graduate from a certified federal, state, county, local or military law enforcement training academy or program that provided instruction on the use of police powers in an armed capacity while dealing with the public?

ARREST AUTHORITY VERTIFICATION: You must verify the applicant's arrest authority and obtain a copy of the applicant's training certificate or diploma prior to submitting the applicant's package to the United States Marshals Service. If the applicant did not receive a training certificate or diploma, a letter from the training department or agency may suffice. This letter must indicate that the applicant was employed as a law enforcement officer and that the department or agency did not or does not issue certificates or diplomas upon completion of such training.

Employment Verification (to include Law Enforcement Experience): Applicants are required to have at least 3 total years of law enforcement experience within the past 7 years. You must verify the applicant's law enforcement experience with the applicant's previous employer(s). List experience below, starting with most recent. If additional space is required, use continuation page.

Employment #1

7. Retired?

8. If possible, would the employer rehire the applicant?

9. Which representative of this organization verified the applicant's law enforcement employment history?

Experience Validated?

OR

Employment #2

7. Retired?

8. If possible, would the employer rehire the applicant?

9. Which representative of this organization verified the applicant's law enforcement employment history?

Experience Validated?

OR

PART III - TO BE COMPLETED BY APPLICANT

1. YOUR EMPLOYMENT HISTORY

Has any of the following happened to you during your employment history in the last 7 years?

1 - Fired from a job.

2 - Quit a job after being told you'd be fired.

3 - Left a job by mutual agreement following allegations of misconduct/unsatisfactory performance.

4 - Left a job for other reasons under unfavorable circumstances.

5 - Retired in lieu of termination.

6 - Retired while under investigation.

** Select the code from above and explain the reason your employment was ended:

Month/Year Code Specify Reason Employer's name and address (include state/zip code)

PART IV - TO BE COMPLETED BY APPLICANT

1. Your Financial Record a.) In the last 7 years, have you, or a company over which you exercised some control, filed bankruptcy, been declared bankrupt, been subject to tax lien, or had legal judgment rendered against you for a debt?

b.) Are you now over 180 days delinquent on any loan or financial obligation?

c.) Are you delinquent on any Federal debt (Federal taxes, loans or other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans?

APPLICANT'S SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION

I have the knowledge and understanding that any or all items contained herein may be subject to investigation and I consent to the release of information concerning my capacity and fitness by employers, educational institutions, law enforcement agencies, and other individuals and agencies, and other authorized employees of my potential employer, who is under contract with the Federal Government (United States Marshals Services) for that purpose.

CERTIFICATION: I certify that all of the statements are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

CONTRACTOR'S SIGNATURE AND CERTIFICATION STATEMENT

I hereby certify that I have been authorized by my employer, to conduct a complete and thorough preliminary background check on the subject applicant, whom my employer is seeking to hire, and/or provide as a qualified candidate for a CSO position. I also certify that the findings resulting from the preliminary background check have been stated in a true, complete, and accurate manner.

INSTRUCTIONS FOR COMPLETION OF THIS FORM

1. Complete all fields. Incomplete forms will not be accepted.

2. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

3. You must use U.S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.

4. All telephone numbers must include area codes.

5. All dates provided on this form must be in Month/Day/Year (mm/dd/yyyy) or Month/Year (mm/yyyy) format. Use numbers (1-12) to indicate months. For example, August 15, 2017 should be shown as 08/15/2017.

6. If you need additional space to complete this form, please use a separate blank sheet of paper. Include the applicant's name and Social Security number on each sheet. Specify the question number for which you are providing additional details.

7. Documentation: Provide documentation to verify any significant claims or activities, such as:

- naturalization certificate;

- originals or certified copies of college transcripts or degree;

- professional license(s) or certificate(s);

- military discharge certificate(s) (DD Form 214); and/or

- passport.

8. NAME CHANGES: If you have had a name change from that indicated on the form, you must provide a copy of the documentation of any legal name change. If the name you are currently using is not a legal name, please use your official name as indicated on your birth certificate or marriage license.

9. EMPLOYMENT: Ensure that you list previous law enforcement related employment, including military (e.g., Military Police).

10. FINANCIAL RECORD: Please check the corresponding boxes to the financial questions listed.

PURPOSE OF THIS FORM

This form is the basis for an initial background investigation that will be used to determine your qualifications (to include law enforcement qualifications) and suitability to work for the U.S. Government under contract.

AUTHORITY TO REQUEST THIS INFORMATION

The U.S. Government is authorized to ask for this information under 5 U.S.C. 3301 and 28 U.S.C. 561. Your Social Security number is needed to keep records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

THE BACKGROUND CHECK PROCESS

The U.S. Marshals Service (USMS) inputs the information from this completed form into the NCIC Database and conducts a pre-employment name check through the National Crime Information Center (NCIC). The system will produce a criminal history report that is reviewed by designated USMS personnel. The designated USMS personnel will determine the eligibility of the temporary contractor based upon the information provided by the check.

FINAL DETERMINATION ON YOUR ELIGIBILITY

Final determination on your eligibility for a position is the responsibility of the USMS. You may be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made.

AUTHORIZATION AND RELEASE

I hereby authorize the USMS and other authorized Federal agencies 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 U.S. Department of Homeland Security (DHS), (if applicable). This authorization is valid for one year from the date this form was signed.

I have been notified of any employer’s right to require a criminal history records check as a condition of employment. I understand that I may request a copy of such records as may be available to me under the law. 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.

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.

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

Providing the information on this form is voluntary, however, failure to furnish the requested information may delay or prevent action on your employment. In addition, incomplete, misleading, or untruthful information provided on the form may result in delays in processing the form for employment, termination of employment, or criminal sanction.

PRIVACY ACT ROUTINE USES

This form or information contained therein may be disclosed in accordance with the routine disclosures set forth in the Office of Personnel Management government-wide system of records, OPM/Govt-1, General Personnel Records, 76 Fed. Reg. 32997 (June 7, 2011), including but not limited to:

1. The disclosure of pertinent information to the appropriate Federal, State, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order, when the disclosing agency becomes aware of an indication of a violation or potential violation or potential violation of civil or criminal law or regulation.

2. The disclosure of information to any source from which additional information is requested (to the extent necessary to identify the individual inform the source of the purpose(s) of the request, and to identify the type of information requested), when necessary to obtain information relevant to an agency decision to hire or retain an employee, issue a security clearance, conduct a security or suitability investigation of an individual, classify jobs, let a contract, or issue a license, grant, or other benefits.

3. The disclosure to a Federal agency in the executive, legislative, or judicial branch of Government, in response to its request, or at the initiation of the agency maintaining the records, information in connection with the hiring of an employee, the issuance of a security clearance or determination concerning eligibility to hold a sensitive position, the conducting of an investigation for purposes of a credentialing, national security, fitness, or suitability adjudication concerning an individual, the classifying or designation of jobs, the letting of a contract, the issuance of a license, grant, or other benefit by the requesting agency, or the lawful statutory, administrative, or investigative purpose of the agency to the extent that the information is relevant and necessary to the requesting agency's decision.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this to Office of Court Security, 14th Floor, U.S. Marshals Service, Washington, DC 20530-0001. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

9.0.0.2.20101008.1.734229