USM-271.pdf

Form USM-271 Rev. 05/19 Page of

U.S. Department of Justice United States Marshals Service Leased/Charter/Contract Personnel Expedited Clearance Request

OMB Number 1105-0097 (Exp. 05/31/2025)

1. Last Name: 2. First Name: 3. Middle Name (Full):

4. Other Names Used: 5. Social Security Number:

6. Date of Birth: 7. Place of Birth: 8. Citizenship:

9. Gender (M or F): 10. Race: 11. Height: 12. Weight (lbs.): 13. Eye Color:

14. Home Address - Street: 15. City: 16. State: 17. ZIP Code:

18. Driver's License #: 19. Issuing State: 20. Occupation (Pilot / Flight Attendant / Mechanic / Nurse / Other):

21. List all of the U.S. states you have lived in within the past 10 years (use state abbreviations):

22. Have you ever been arrested?

YesNo

23. If yes, list charge/violation/disposition:

CERTIFICATION: I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I have read and understand the information on the second page of this form, and I authorize the use and release of this information in accordance with the stated purpose.

24. Signature of Applicant: 25. Printed Name: 26. Date:

TO BE COMPLETED BY USMS PERSONNEL

1. NCIC Check Completed By: 2. Date: 3. Time:

4. Wanted Person? Yes No 5. Criminal History? Yes No

6. Remarks:

TO BE COMPLETED BY THE USMS JUSTICE PRISONER AND ALIEN TRANSPORTATION SYSTEM (JPATS)

1. NCIC Check Received By: 2. Date: 3. Time:

4. Clearance Granted? Yes No

5. Remarks:

Page of

PURPOSE OF THIS FORM

The U.S. Government conducts criminal checks to establish that applicants or incumbents either employed by the Government or working for the Government under contract are eligible for the job. The U.S. Marshals Service will use this form to conduct a National Criminal Information Center (NCIC) check for each temporary contractor (working on contract 6 months or less and require physical access only) to determine eligibility to work on U.S. Marshals Service contracts.

AUTHORITY TO REQUEST THIS INFORMATION

The U.S. Government is authorized to ask for this information under 5 CFR 731, Suitability Regulations. 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 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 U.S. Marshals Service personnel. The designated U.S. Marshals Service 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 U.S. Marshals Service. 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 U.S. Marshals Service 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

Solicitation of information contained herein is authorized by Executive Order 10450 and may be used as a basis for eligibility determinations. The USMS describes how your information will be maintained in the Privacy Act system of record notice published in the Federal Register at 67 FR 59864, 69 (September 24, 2002). 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 eligibility 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.

PRIVACY ACT ROUTINE USES

Records or information in this system of records may be disclosed to the following parties when it has been determined by the Department of Justice that such a need exists:

(1) Designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government, in connection with the hiring or continued employment of an employee or contractor, the conduct of a suitability or security investigation of an employee or contractor, or the grant, renewal, suspension, or revocation of a security clearance, to the extent that the information is relevant and necessary to the hiring agency's decision.

(2) Designated officers and employees of state or local (including the District of Columbia) law enforcement or detention agencies in connection with the hiring or continued employment of an employee or contractor, where the employee or contractor would occupy or occupies a position of public trust as a law enforcement officer or detention officer having direct contact with the public or with prisoners or detainees, to the extent that the information is relevant and necessary to the recipient agency's decision.

(3) In the event that a record in this system, either alone or in conjunction with other information, indicates a violation or potential violation of law -- criminal, civil, or regulatory in nature -- the relevant records may be referred to the appropriate federal, state, local, foreign, or tribal law enforcement authority or other appropriate agency charged with the responsibility for investigating or prosecuting such violation or charged with enforcing or implementing such law.

(4) A Member of Congress or staff acting upon the Member's behalf when the Member or staff requests the information on behalf of and at the request of the individual who is the subject of the record.

(5) The National Archives and Records Administration and the General Services Administration in records management inspections conducted under the authority of 44 U.S.C. 2904 and 2906.

(6) An actual or potential party to litigation or the party's authorized representative for the purpose of negotiation or discussion on such matters as settlement, plea bargaining, or in informal discovery proceedings.

(7) Such recipients and under such circumstances and procedures as are mandated by federal statute or treaty.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 5 minutes 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 JPATS, U.S. Marshals Service, 1251 NW Briarcliff Parkway, Suite 300, Kansas City, MO 64116. 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.

INSTRUCTIONS FOR LEASED/CHARTER PERSONNEL TO COMPLETE THIS FORM

1. Complete all fields. 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."

2. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, USMS may modify the form consistent with your intent.

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/yy) or Month/Year (mm/yy) format. Use numbers (1-12) to indicate months. For example, May 27, 1972 should be shown as 5/27/72.

6. Question 9 (nine) should be answered from the following available choices in NCIC: F-Female; M-Male; or U-Unknown

7. Question 10 (ten) should be answered from the following available choices in NCIC: I-American Indian or Alaskan Native; A-Asian or Pacific Islander;

B-Black; U-Unknown; W-White or White Hispanic

8. If you need additional space to complete this form, please use a separate blank sheet of paper.

Form USM-271 Rev. 05/19 Page of Page of U.S. Department of Justice United States Marshals Service Leased/Charter/Contract Personnel Expedited Clearance Request OMB Number 1105-0097 (Exp. 05/31/2025)

22. Have you ever been arrested?

CERTIFICATION: I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I have read and understand the information on the second page of this form, and I authorize the use and release of this information in accordance with the stated purpose.

TO BE COMPLETED BY USMS PERSONNEL

4. Wanted Person?

5. Criminal History?

TO BE COMPLETED BY THE USMS JUSTICE PRISONER AND ALIEN TRANSPORTATION SYSTEM (JPATS)

4. Clearance Granted?

PURPOSE OF THIS FORM

The U.S. Government conducts criminal checks to establish that applicants or incumbents either employed by the Government or working for the Government under contract are eligible for the job. The U.S. Marshals Service will use this form to conduct a National Criminal Information Center (NCIC) check for each temporary contractor (working on contract 6 months or less and require physical access only) to determine eligibility to work on U.S. Marshals Service contracts.

AUTHORITY TO REQUEST THIS INFORMATION

The U.S. Government is authorized to ask for this information under 5 CFR 731, Suitability Regulations. 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 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 U.S. Marshals Service personnel. The designated U.S. Marshals Service 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 U.S. Marshals Service. 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 U.S. Marshals Service 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

Solicitation of information contained herein is authorized by Executive Order 10450 and may be used as a basis for eligibility determinations. The USMS describes how your information will be maintained in the Privacy Act system of record notice published in the Federal Register at 67 FR 59864, 69 (September 24, 2002). 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 eligibility 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.

PRIVACY ACT ROUTINE USES

Records or information in this system of records may be disclosed to the following parties when it has been determined by the Department of Justice that such a need exists:

(1) Designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government, in connection with the hiring or continued employment of an employee or contractor, the conduct of a suitability or security investigation of an employee or contractor, or the grant, renewal, suspension, or revocation of a security clearance, to the extent that the information is relevant and necessary to the hiring agency's decision.

(2) Designated officers and employees of state or local (including the District of Columbia) law enforcement or detention agencies in connection with the hiring or continued employment of an employee or contractor, where the employee or contractor would occupy or occupies a position of public trust as a law enforcement officer or detention officer having direct contact with the public or with prisoners or detainees, to the extent that the information is relevant and necessary to the recipient agency's decision.

(3) In the event that a record in this system, either alone or in conjunction with other information, indicates a violation or potential violation of law -- criminal, civil, or regulatory in nature -- the relevant records may be referred to the appropriate federal, state, local, foreign, or tribal law enforcement authority or other appropriate agency charged with the responsibility for investigating or prosecuting such violation or charged with enforcing or implementing such law.

(4) A Member of Congress or staff acting upon the Member's behalf when the Member or staff requests the information on behalf of and at the request of the individual who is the subject of the record.

(5) The National Archives and Records Administration and the General Services Administration in records management inspections conducted under the authority of 44 U.S.C. 2904 and 2906.

(6) An actual or potential party to litigation or the party's authorized representative for the purpose of negotiation or discussion on such matters as settlement, plea bargaining, or in informal discovery proceedings.

(7) Such recipients and under such circumstances and procedures as are mandated by federal statute or treaty.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 5 minutes 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 JPATS, U.S. Marshals Service, 1251 NW Briarcliff Parkway, Suite 300, Kansas City, MO 64116. 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.

INSTRUCTIONS FOR LEASED/CHARTER PERSONNEL TO COMPLETE THIS FORM

1. Complete all fields. 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."

2. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, USMS may modify the form consistent with your intent.

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/yy) or Month/Year (mm/yy) format. Use numbers (1-12) to indicate months. For example, May 27, 1972 should be shown as 5/27/72.

6. Question 9 (nine) should be answered from the following available choices in NCIC: F-Female; M-Male; or U-Unknown

7. Question 10 (ten) should be answered from the following available choices in NCIC: I-American Indian or Alaskan Native; A-Asian or Pacific Islander;

B-Black; U-Unknown; W-White or White Hispanic

8. If you need additional space to complete this form, please use a separate blank sheet of paper.

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