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Questionnaire For National Security Positions
To the Office of Management and Budget when necessary to the review of
private relief legislation.
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The 5-digit postal Zip Codes are required to process your investigation
more rapidly. Refer to an automated system approved by the U.S. Postal
Service to assist you with Zip Codes.
For telephone numbers in the U.S., ensure that the area code is included.
All dates provided in this form must be in Month/Day/Year or Month/Year
format. Use numbers (01-12) to indicate months. For example, July 29,
1968, should be written as 07/29/1968. If you are unable to report an
exact date, approximate or estimate the date to the best of your ability,
and indicate "APPROX." or "EST" in the field.
If additional space is required for an explanation or to list your residences,
employment/self- employment/unemployment, or education, you should
use a continuation sheet, SF 86A, located at http://www.opm.gov/forms,
select standard forms. If additional space is required to answer other
items, use the Continuation Space, on page 121, or a blank sheet(s) of
paper. Include your name and SSN at the top of each blank sheet (s)
used.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
The U.S. Criminal Code (title 18, section 1001) provides that knowingly
falsifying or concealing a material fact is a felony which may result in fines
and/or up to five (5) years imprisonment. In addition, Federal agencies
generally fire, do not grant a security clearance, or disqualify individuals who
have materially and deliberately falsified these forms, and this remains a part
of the permanent record for future placements. Your prospects of placement
or security clearance are better if you answer all questions truthfully and
completely. You will have adequate opportunity to explain any information you
provide on this form and to make your comments part of the record.
Penalties for Inaccurate or False Statements
The information you provide is for the purpose of investigating you for a
national security position, and the information will be protected from
unauthorized disclosure. The collection, maintenance, and disclosure of
background investigative information are governed by the Privacy Act. The
agency that requested the investigation and the agency that conducted the
investigation have published notices in the Federal Register describing the
systems of records in which your records will be maintained. The information
you provide on this form, and information collected during an investigation,
may be disclosed without your consent by an agency maintaining the
information in a system of records as permitted by the Privacy Act [5 U.S.C.
552a(b)], and by routine uses, a list of which are published by the agency in
the Federal Register. The office that gave you this form will provide you a
copy of its routine uses.
Disclosure Information
Privacy Act Routine Uses
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1. To the Department of Justice when: (a) the agency or any component
thereof; or (b) any employee of the agency in his or her official capacity; or
(c) any employee of the agency in his or her individual capacity where the
Department of Justice has agreed to represent the employee; or (d) the
United States Government, is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records
are both relevant and necessary to the litigation and the use of such
To a court or adjudicative body in a proceeding when: (a) the agency or
any component thereof; or (b) any employee of the agency in his or her
official capacity; or (c) any employee of the agency in his or her individual
capacity where the Department of Justice has agreed to represent the
employee; or (d) the United States Government is a party to litigation or
has interest in such litigation, and by careful review, the agency
determines that the records are both relevant and necessary to the
litigation and the use of such records is therefore deemed by the agency
to be for a purpose that is compatible with the purpose for which the
agency collected the records.
Except as noted in Sections 23 and 27, when a record on its face, or in
conjunction with other records, indicates a violation or potential violation of
law, whether civil, criminal, or regulatory in nature, and whether arising by
general statute, particular program statute, regulation, rule, or order issued
pursuant thereto, the relevant records may be disclosed to the appropriate
Federal, foreign, State, local, tribal, or other public authority responsible for
enforcing, investigating or prosecuting such violation or charged with
enforcing or implementing the statute, rule, regulation, or order.
To any source or potential source from which information is requested in the
course of an investigation concerning the hiring or retention of an employee
or other personnel action, or the issuing or retention of a security clearance,
contract, grant, license, or other benefit, to the extent necessary to identify
the individual, inform the source of the nature and purpose of the
investigation, and to identify the type of information requested.
To a Federal, State, local, foreign, tribal, or other public authority the fact
that this system of records contains information relevant to the retention of
an employee, or the retention of a security clearance, contract, license,
grant, or other benefit. The other agency or licensing organization may
then make a request supported by written consent of the individual for the
entire record if it so chooses. No disclosure will be made unless the
information has been determined to be sufficiently reliable to support a
referral to another office within the agency or to another Federal agency
for criminal, civil, administrative, personnel, or regulatory action.
To contractors, grantees, experts, consultants, or volunteers when
necessary to perform a function or service related to this record for which
they have been engaged. Such recipients shall be required to comply with
the Privacy Act of 1974, as amended.
To the news media or the general public, factual information the disclosure
of which would be in the public interest and which would not constitute an
unwarranted invasion of personal privacy.
To a Member of Congress or to a Congressional staff member in response
to an inquiry of the Congressional office made at the written request of the
constituent about whom the record is maintained.
To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
To a Federal, State, or local agency, or other appropriate entities or
individuals, or through established liaison channels to selected foreign
governments, in order to enable an intelligence agency to carry out its
responsibilities under the National Security Act of 1947 as amended, the
CIA Act of 1949 as amended, Executive Order 12333 or any successor
order, applicable national security directives, or classified implementing
procedures approved by the Attorney General and promulgated pursuant
to such statutes, orders or directives.
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Final determination on your eligibility for a national security position is the
responsibility of the Federal agency that requested your investigation and the
agency that conducted your investigation. You will be provided the opportunity
to explain, refute, or clarify any information before a final decision is made, if
an unfavorable decision is considered. The United States Government does
not discriminate on the basis of race, color, religion, sex, national origin,
disability, or sexual orientation when granting access to classified information.
Final Determination on Your Eligibility
records by the Department of Justice is therefore deemed by the agency
to be for a purpose that is compatible with the purpose for which the
agency collected the records.
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