Standard Form 86C Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 STANDARD FORM 86 CERTIFICATION (SF 86C) Form approved: OMB No. 3206 0005 NSN 7540-01-500-4881 86-111 Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on page 2. If you have any questions, contact the office that gave you this form. The Standard Form 86 (SF 86), Questionnaire for National Security Positions, is completed by persons under consideration for or retention in national security positions as defined in 5 CFR 732 and for positions requiring access to classified information, as defined in Executive Order 12968. Depending upon the purpose of your investigation, the United States (U.S) Government is authorized to ask for this information under Executive Orders 10450, 10865, 12333, and 12968; Sections 3301, 3302, and 9101 of title 5, U.S. Code (U.S.C.); Sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50, U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal Regulations. There are many situations where individuals are required to fill out a new SF 86 when the sole purpose is to determine if any information on a previously executed SF 86 has changed. This requires extensive work by the individual even if nothing has changed. The SF 86C is a certification document that allows the reporting of changes in previously reported information on the SF 86. This certification will be in lieu of completing a new SF 86 and will allow the individual to indicate that there have been no changes in the data provided on the most recently filed SF 86 or it will allow the individual to easily provide new or changed information. No investigation will be initiated based solely on the execution of this form. Your Social Security Number (SSN) is needed to identify your unique records. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397. PRIVACY ACT ROUTINE USES 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 dividual 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 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. 5. 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. 2. 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. 6. 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. 3. Except as noted in Question 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. 4. 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 etention 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. 7. 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. 8. 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. 9. 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. 10. To the National Archives and Records Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906. 11. To the Office of Management and Budget when necessary to the review of private relief legislation. PUBLIC BURDEN INFORMATION Public burden reporting for this collection of information averages 15 minutes, including 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 the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street NW, Washington, DC 20415. Do not send your completed form to this address, send it to the office that provided you the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 86C Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 NSN 7540-01-500-4881 86-111 STANDARD FORM 86 CERTIFICATION (SF 86C) INSTRUCTIONS: Type or legibly print your answers in ink (if this form is not legible, it will not be accepted). Complete this form referencing information contained in your most recent SF 86 or information disclosed upon the date of your last background investigation. All questions on this form must be answered. 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 your response(s) consistent with your intent. The United States 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 5 years of imprisonment. Do not provide information you have already provided on your most recent SF 86. Any "Yes" responses under Block 2 must be explained in Block 3. If additional space is needed, use a blank sheet of paper. Each blank sheet of paper you use must contain your name and SSN at the top of the page. Conclude by certifying the accuracy of your answers in Block 4, Certification. If you have any questions, contact the office that gave you the form, or a Government security officer. Block 1 - Identification Full name (last, first, middle, maiden) Social Security Number (SSN) Date of birth (mm/dd/yyyy ) Place of birth (include City (Country) and State) Work telephone number Home telephone number E-mail Block 2 – Questions from the SF 86 INSTRUCTIONS: The following Questions correlate with your SF 86. If you report no change to a Question, place an "X" in the No box. If there is a change , place an "X" in the Yes box. All Yes answers must be explained under Block 3, Explanations/Remarks. Yes No Question 1. Full Name Question 4. Social Security Number Question 5. Other Names Used Question 9. Citizenship Question 10. Citizenship Information Question 11. Where You Have Lived Question 12. Where You Went to School Question 13. Employment Activities Question 14. Selective Service Record Question 15. Military History Question 17. Marital Status Question 18. Relatives Question 19. Foreign Contacts Question 20. Foreign Activities Question 21. Mental and Emotional Health Question 22. Police Record Question 23. Use of Illegal Drugs and Drug Activity Question 24. Use of Alcohol Question 25. Investigations and Clearance Record Question 26. Financial Record Question 27. Use of Information Technology Systems Question 28. Involvement in Non-Criminal Court Actions Question 29. Association Record Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 86C Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 STANDARD FORM 86 CERTIFICATION (SF 86C) Form approved: OMB No. 3206 0005 NSN 7540-01-500-4881 86-111 Block 3 – Explanations/Remarks INSTRUCTIONS: Before each answer, identify the SF 86 Question number associated with your answer. For example, if you have had a change of residence, write "Question 11" and list your new address. Check this block if additional comments are attached. Place your name and SSN at the top of each page. Check this block if your SF 86 is attached. Block 4 – Certification I certify that the above information includes all changes to my most recent SF 86 or since my last investigation. Changes, if any, are explained under Block 3. My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information will have a negative affect on my security clearance, employment prospects, or job status up to and including denial or revocation of my security clearance, or my removal and debarment from Federal service. Signature (Sign in Ink) Date (mm/dd/yyyy) Enter your Social Security Number before going to the next page Page 2 American LegalNet, Inc. www.FormsWorkFlow.com