VBA-20-10276-ARE.pdf

SECTION I: APPLICANT INFORMATION (Completed by Applicant)

SECTION II: CONTRACT INFORMATION (Completed by Contracting Officer Representative (COR))

SECTION III: CONTRACTING OFFICER REPRESENTATIVE INFORMATION (Completed by COR)

SECTION IV: SPONSOR INFORMATION

VBA CONTRACTOR BACKGROUND INVESTIGATION REQUEST

Before completing this form, read the Privacy Act and Respondent Burden on Page 2. Use this form to submit contractor background investigation requests. If you have questions about this request form, we can be reached by telephone (202) 461-9422 or by email at PersonnelSecurity.vbaco@va.gov. After completing the form, the Contracting Officer Representative (COR) will upload it to:

https://va-vet.lightning.force.com.

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and completely fill in each applicable check box to help expedite processing of the form.

1. APPLICANT'S LEGAL NAME (First, Middle Initial, Last)

3. COUNTRY OF BIRTH 4. CITY AND STATE OF BIRTH

6. CITIZENSHIP

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

8. NAME AND ADDRESS OF ASSIGNED DUTY STATION (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

9. EMAIL ADDRESS (REQUIRED)

10. NAME OF CONTRACTOR'S COMPANY

12. COMPANY/VENDOR POINT OF CONTACT (POC)

13. POC TELEPHONE NUMBER 14. POC EMAIL ADDRESS

OMB Control No. 2900-0915 Respondent Burden: 10 Minutes Expiration Date: 09/30/2025

15. NAME OF CONTRACTING OFFICER REPRESENTATIVE (COR)

17. COR EMAIL ADDRESS16. COR LOCATION (City and State)

19. NAME OF SPONSOR CONTRACTING OFFICER REPRESENTATIVE (COR)

11A. CONTRACT NUMBER

20. NAME AND ADDRESS OF FACILITY OR ASSIGNED DUTY STATION

VA FORM

SEP 2022 20-10276 Page 1

INSTRUCTIONS:

2. SOCIAL SECURITY NUMBER

5. DATE OF BIRTH (MM/DD/YYYY)

21. TYPE OF PERSONNEL IDENTIFICATION VERIFICATION (PIV) REQUEST (Select one) 22. TYPE OF ACCESS (Select one)

11B. CONTRACT START DATE (MM/DD/YYYY) 11C. CONTRACT END DATE (MM/DD/YYYY)

18. COR BUSINES LINE/STAFF OFFICE/REGIONAL OFFICE

mailto:PersonnelSecurity.vbaco@va.gov https://va-vet.lightning.force.com

SECTION VI: APPLICANT SELF CERTIFICATION OF CONTINUOUS SERVICE

SECTION VII: CERTIFICATION AND SIGNATURE

SECTION V: TYPE OF BACKGROUND CHECK

24. Federal employment is defined as service in any branch of the United States military (Active, Guard, or Reserve), federal government civilian employment (any federal government agency), or a contractor working for the federal government. I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I have NOT had a break in service. (Select one option)

My break in service is greater than two (2) years OR I have never had federal employment as defined above.

My break in service was greater than 60 days, but less than two (2) years.

My break in service was less than 60 days.

My service was intra-agency (i.e., VA, VBA, VHA, NCA)

My service was inter-agency (other government agency, i.e., DOD, FBI, CIA, DOS, HHS, DHS, NSA, DOJ, NIH, etc.)

25. SIGNATURE OF APPLICANT

I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.

27. SIGNATURE (REQUIRED)

The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.

VA FORM 20-10276, SEP 2022

23. SELECT TYPE

23B. DATE SAC INITIATED

(MM/DD/YYYY)

23D. DATE SAC ADJUDICATED

(MM/DD/YYYY)

23A. DATE INITIATED BACKGROUND

INVESTIGATION (MM/DD/YYYY)

26. DATE (MM/DD/YYYY)

28. DATE SIGNED (MM/DD/YYYY)

VA is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (HSPD)-12, and 31 USC 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under HSPD-12 are used to verify the personal identity of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contractors, and affiliates issued a Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 USC Section 552(a) and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)".

VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including civil or criminal law enforcement, constituent congressional communications initiated at your request, litigation, or administrative proceedings in which the United States is a party or has an interest, the administration of VA programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of the requested information may result in VA being unable to process your request for a Personal Identity Verification Card, or denial of issuance of a Personal Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to VA facilities or networks, which could have an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perform your assigned duties or responsibilities.

PRIVACY ACT STATEMENT:

PENALTY:

23C. DATE ADJUDICATED BACKGROUND

INVESTIGATION (MM/DD/YYYY)

RESPONDENT BURDEN: This form is used to request information that is necessary for the validation and determinations of suitability and trustworthiness of the applicant in order to to adjudicate the background investigation requirements so that the applicant can receive a personal identity verification (PIV) Card to access VA systems. It should take you about 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid Office of Management and Budget (OMB) control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can contact Joylisa Jenkins at Joylisa.Jenkins@va.gov to get information on where to send comments or suggestions about this form.

www.reginfo.gov/public/do/PRAMain mailto:Joylisa.Jenkins@va.gov

SECTION I: APPLICANT INFORMATION (Completed by Applicant) SECTION II: CONTRACT INFORMATION (Completed by Contracting Officer Representative (COR)) SECTION III: CONTRACTING OFFICER REPRESENTATIVE INFORMATION (Completed by COR)

SECTION IV: SPONSOR INFORMATION

VBA CONTRACTOR BACKGROUND INVESTIGATION REQUEST

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs Logo.

Before completing this form, read the Privacy Act and Respondent Burden on Page 2. Use this form to submit contractor background investigation requests. If you have questions about this request form, we can be reached by telephone (202) 461-9422 or by email at PersonnelSecurity.vbaco@va.gov. After completing the form, the Contracting Officer Representative (COR) will upload it to:

https://va-vet.lightning.force.com.

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and completely fill in each applicable check box to help expedite processing of the form.

OMB Control No. 2900-0915 Respondent Burden: 10 Minutes Expiration Date: 09/30/2025

VA FORM SEP 2022

20-10276

INSTRUCTIONS:

SECTION VI: APPLICANT SELF CERTIFICATION OF CONTINUOUS SERVICE

SECTION VII: CERTIFICATION AND SIGNATURE

SECTION V: TYPE OF BACKGROUND CHECK

24. Federal employment is defined as service in any branch of the United States military (Active, Guard, or Reserve), federal government civilian employment (any federal government agency), or a contractor working for the federal government. I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.

The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.

VA FORM 20-10276, SEP 2022

VA is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (HSPD)-12, and 31 USC 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under HSPD-12 are used to verify the personal identity of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contractors, and affiliates issued a Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 USC Section 552(a) and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)". VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including civil or criminal law enforcement, constituent congressional communications initiated at your request, litigation, or administrative proceedings in which the United States is a party or has an interest, the administration of VA programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of the requested information may result in VA being unable to process your request for a Personal Identity Verification Card, or denial of issuance of a Personal Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to VA facilities or networks, which could have an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perform your assigned duties or responsibilities.

PRIVACY ACT STATEMENT:

PENALTY:

RESPONDENT BURDEN: This form is used to request information that is necessary for the validation and determinations of suitability and trustworthiness of the applicant in order to to adjudicate the background investigation requirements so that the applicant can receive a personal identity verification (PIV) Card to access VA systems. It should take you about 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid Office of Management and Budget (OMB) control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can contact Joylisa Jenkins at Joylisa.Jenkins@va.gov to get information on where to send comments or suggestions about this form.

6.5.0.20190320.2.935878.932721 VA Form 20-10276

BACKGROUND INVESTIGATION REQUEST

VBA

Y. Allmond

SEP 2022

SEP 2022