6WDQGDUG )RUP 5HYLVHG 'HFHPEHU 86 2IILFH RI 3HUVRQQHO 0DQDJHPHQW &)5 3DUWV DQG )RUP DSSURYHG 20% 1R Questionnaire for Non-Sensitive Positions Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 5 and the release on Page 6. If you have any questions, call the office that gave you the form. Purpose of this Form The U.S. Government conducts background investigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job. Information from this form is used primarily as the basis for this investigation. Complete this form only after a conditional offer of employment has been made. Giving us the information we ask for is voluntary. However, we may not be able to complete your investigation, or complete it in a timely manner, if you don't give us each item of information we request. This may affect your placement or employment prospects. 2. Type or legibly print your answers in black ink (if your form is not legible, it will not be accepted). You may also be asked to submit your form in an approved electronic format. 3. All questions on this form must be answered. 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." Authority to Request this Information The U.S. Government is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code; and parts 5, 731, and 736 of Title 5, Code of Federal 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. 4. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, agencies may modify the form consistent with your intent. 5. You must use the State codes (abbreviations) listed on the back of this page when you fill out this form. Do not abbreviate the names of cities or foreign countries. 6. The 5-digit postal ZIP codes are needed to speed the processing of your investigation. The office that provided the form will assist you in completing the ZIP codes. The Investigative Process Background investigations are conducted using your responses on this form and on your Declaration for Federal Employment (OF 306) to develop information to show whether you are reliable, trustworthy, and of good conduct and character. Your current employer must be contacted as part of the investigation, even if you have previously indicated on applications or other forms that you do not want this. 7. All telephone numbers must include area codes. 8. All dates provided on this form must be in Month/Day/Year or Month/Year format. Use numbers (1-12) to indicate months. For example, June 10, 1978, should be shown as 6/10/78. 9. Whenever "City (Country)" is shown in an address block, also provide in that block the name of the country when the address is outside the United States. Instructions for Completing this Form 1. Follow the instructions given to you by the person who gave you the form and any other clarifying instructions furnished by that person to assist you in completion of the form. Find out how many copies of the form you are to turn in. You must sign and date, in black ink, the original and each copy you submit. 10. If you need additional space to list your residences or employments/self-employments/unemployment or education, you should use a continuation sheet, SF 86A. If additional space is needed to answer other items, use a blank piece of paper. Each blank piece of paper you use must contain your name and Social Security Number at the top of the page. American LegalNet, Inc. www.FormsWorkFlow.com Final Determination on Your Eligibility Final determination on your eligibility for a position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made. Penalties for Inaccurate or False Statements 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 of up to $10,000, and/or 5 years imprisonment, or both. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Your trustworthiness is a very important consideration in deciding your suitability. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you give us on the form and to make your comments part of the record. Disclosure of Information The information you give us is for the purpose of determining your suitability for Federal employment; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information is governed by the Privacy Act. The agency which requested the investigation and the agency which conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. You may obtain copies of the relevant notices from the person who gave you this form. The information on this form, and information we collect during an investigation may be disclosed without your consent as permitted by the Privacy Act (5 USC 552a(b)) and as follows: PRIVACY ACT ROUTINE USES 7R WKH 'HSDUWPHQW RI -XVWLFH ZKHQ D WKH DJHQF\ RU DQ\ FRPSRQHQW WKHUHRI RU E DQ\ HPSOR\HH RI WKH DJHQF\ LQ KLV RU KHU RIILFLDO FDSDFLW\ RU F DQ\ HPSOR\HH RI WKH DJHQF\ LQ KLV RU KHU LQGLYLGXDO FDSDFLW\ ZKHUH WKH 'HSDUWPHQW RI -XVWLFH KDV DJUHHG WR UHSUHVHQW WKH HPSOR\HH RU G WKH 8QLWHG 6WDWHV *RYHUQPHQW LV D SDUW\ WR OLWLJDWLRQ RU KDV LQWHUHVW LQ VXFK OLWLJDWLRQ DQG E\ FDUHIXO UHYLHZ WKH DJHQF\ GHWHUPLQHV WKDW WKH UHFRUGV DUH ERWK UHOHYDQW DQG QHFHVVDU\ WR WKH OLWLJDWLRQ DQG WKH XVH RI VXFK UHFRUGV E\ WKH 'HS