Attachment_002_OFI_86C_Special_Agreement_Checks.pdf

SPECIAL AGREEMENT CHECKS (SAC)

OFI FORM 86C U.S. OFFICE OF PERSONNEL MANAGEMENT

MAY 2010 INVESTIGATIVE SERVICES

Agency Agreement Number

OPM

USE

ONLY

OPM Codes

Case Number

AGENCY USE ONLY (COMPLETE ITEMS 1 THROUGH 14 USING INSTRUCTIONS FROM THE BACK)

1. SUBJECT’S FULL NAME 2 DATE OF BIRTH

Last Name

First Name

Middle Name

Abbrev.

Month Day Year

3. PLACE OF BIRTH ∙ Use the 2 letter code for the state 4 SOCIAL SECURITY NUMBER City

County

State

Country

5. OTHER NAMES AND DATES WHEN USED

Name Month/Year Month/Year To

Name Month/Year Month/Year To

Name Month/Year Month/Year To

Name Month/Year Month/Year To

6. SEX (Mark one box)

7. SPECIAL AGREEMENT CODES

E, B

8. POSITION TITLE

SON FS00

SOI FS00

11 IPAC-ALC

NUMBER 26000001

12 ACCOUNTING DATA

13 OTHER INFORMATION REQUIRED BY AGREEMENT

(CODE S) Spouse/Cohabitant NACs – Complete if needed

SPOUSE/COHABITANT’S FULL NAME DATE OF BIRTH

Last Name

First Name

Middle Name

Abbrev.

Month Day Year

PLACE OF BIRTH ∙ Use the 2 letter code for the state SOCIAL SECURITY NUMBER

County

Country

OTHER NAMES AND DATES WHEN USED

Name Month/Year Month/Year To

Name Month/Year Month/Year To

Name Month/Year Month/Year To

Name Month/Year Month/Year To

(CODE E, 3, and 8) Credit Record or Child Care searches– Complete if Needed. Fill in subject’s address for every place lived for more than three months in the past 12 months (5 years for Child Care searches). If additional space is needed, attach a continuation sheet to this form.

Month/Year to Month/Year to

Street Address Apt. #

Zip

Month/Year to Month/Year to

Street Address Apt. #

Zip

(CODE I) Citizenship and Immigration information – Complete if Needed. (Code not required if information is provide for subject or spouse/Co- Hab)

Naturalized U.S. Citizen U.S. Citizen or national by birth, born outside the U.S. Not a U.S. Citizen

U.S. PASSPORT current or most recent passport ALIEN REGISTRATION NUMBER (if applicable) Number

Document Number

Expired Y N

Number

DOCUMENTATION OF U.S. CITIZENS BORN ABROAD (STATE DEPARTMENT FORM (FS) 240, DS 1350, FS 545, etc.) Report if applicable Date form was completed

Place of Issuance

CITIZENSHIP CERTIFICATE (if applicable) Where was this certificate issued? City/Court

Certificate Number

Date Issued

NATURALIZATION CERTIFICATE (if applicable) Where was this certificate issued? City/Court

Certificate Number

Date Issued

IMMIGRATION STATUS Place you entered the U.S.

Country(ies) of citizenship

Date of entry

Type of document (I-94, etc.)

(CODE N) Bureau of Vital Statistics – Complete if needed Mother’s Full Name

Mother’s Maiden Name

Father’s Full Name

14 Requesting Official Name and Title Joette R. Durham Security Specialist

Signature

Telephone Number (including area code) (202)639-4422

Date

1. SUBJECT’S FULL NAME 2 DATE OF BIRTH

3. PLACE OF BIRTH

5. OTHER NAMES AND DATES WHEN USED

6. SEX (Mark one box)

(CODE E, 3, and 8) Credit Record or Child Care searches– Complete if Needed. Fill in subject’s address for every place lived for more than three months in the past 12 months (5 years for Child Care searches). If additional space is needed, attach a continuation sheet to this form.

4 SOCIAL SECURITY NUMBER