SF-86 BLANK.pdf

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Form approved:

OMB No. 3206 0005

QUESTIONNAIRE FOR

NATIONAL SECURITY POSITIONS

Standard Form 86 Revised November 2016 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

AUTHORIZATION FOR RELEASE OF INFORMATION

UNITED STATES OF AMERICA

Carefully read this authorization to release information about you, then sign and date it in ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation, reinvestigation, or ongoing evaluation (i.e. continuous evaluation) of my eligibility for access to classified information or, when applicable, eligibility to hold a national security sensitive position to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of information. This information may include, but is not limited to current and historic academic, residential, achievement, performance, attendance, disciplinary, employment, criminal, financial, and credit information, and publicly available social media information. I authorize the Federal agency conducting my investigation, reinvestigation, or ongoing evaluation (i.e. continuous evaluation) of eligibility to disclose the record of investigation or ongoing evaluation to the requesting agency for the purpose of making a determination of suitability, or initial or continued eligibility for a national security position or eligibility for access to classified information.

I Understand that, for these purposes, publicly available social media information includes any electronic social media information that has been published or broadcast for public consumption, is available on request to the public, is accessible on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully accessible to the public. I further understand that this authorization does not require me to provide passwords; log into a private account; or take any action that would disclose non-publicly available social media information.

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.

I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of Investigation, the Department of Defense, the Department of Homeland Security, the Office of the Director of National Intelligence, the Department of State, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in, a national security position, in accordance with 5 U.S.C. 9101. I understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes provided in this Standard Form 86, and that it may be disclosed by the Government only as authorized by law.

I Authorize the information to be used to conduct officially sanctioned and approved personnel security-related studies and analyses, which will be maintained in accordance with the Privacy Act.

Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I occupy a national security sensitive position or require eligibility for access to classified information.

Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)

Other names used Social Security Number

Current street address Apt. # City (Country) State ZIP Code Telephone number

Date of birth