CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86 Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111 For use with the SF 85, Questionnaire for Non-Sensitive Positions; SF 85P, Questionnaire for Public Trust Positions; and SF 86, Questionnaire for National Security Positions INSTRUCTIONS: Use this form to continue your answers to "Where You Have Lived," "Where You Went to School," and/or "Your Employment Activities." Follow the instructions on the form for the particular questions you are answering and give information in the same sequence. Use as many continuation sheets as needed. Your Social Security Number Your Name 11 WHERE YOU HAVE LIVED (Continued) #5 Month/Year To Month/Year Status Own Rent Military housing Other (Explain) Street address Apt.# APO/FPO address State City (Country) Name of person who knows you at this address ZIP Code Apt.# Current address APO/FPO address (if currently applicable) State City (Country) Alternate contact number #6 Month/Year To Month/Year Status Own Rent Relationship Military housing Neighbor Landlord Friend Telephone number ZIP Code Other (Explain) Business associate Street address Apt.# Other (Explain) APO/FPO address State City (Country) Name of person who knows you at this address ZIP Code Apt.# Current address APO/FPO address (if currently applicable) City (Country) State #7 Month/Year Alternate contact number To Month/Year Status Own Rent Relationship Military housing Other (Explain) Neighbor Landlord Friend Telephone number ZIP Code Business associate Other (Explain) Street address Apt.# APO/FPO address City (Country) State Name of person who knows you at this address Current address ZIP Code Apt.# APO/FPO address (if currently applicable) City (Country) State Alternate contact number Relationship Neighbor Landlord Friend Telephone number ZIP Code Business associate Other (Explain) Enter your Social Security Number before going to the next page American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86 Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111 12 WHERE YOU WENT TO SCHOOL (Continued) #6 Month/Year To Month/Year Code Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. Name of school State Street address and City (Country) of school Name of person who knows you Current address #7 Month/Year To Month/Year Code ZIP Code Apt. # State City (Country) YES NO ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. Name of school YES NO Street address and City (Country) of school Name of person who knows you State Current address #8 Month/Year Apt. # State City (Country) To Month/Year Code ZIP Code ZIP Code Name of school Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. YES NO State Street address and City (Country) of school Name of person who knows you #9 Month/Year Apt. # Current address State City (Country) To Month/Year Code ZIP Code ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. Name of school YES NO Street address and City (Country) of school Name of person who knows you State Current address #10 Month/Year Apt. # State City (Country) To Month/Year Code ZIP Code ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. Name of school YES NO Street address and City (Country) of school Name of person who knows you City (Country) State Current address ZIP Code Apt. # State ZIP Code Telephone number Enter your Social Security Number before going to the next page American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86 Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111 13 EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) #5 Dates of Employment Month/Year To Month/Year Type of Employment Employment code Position title/Military rank Work hours Employer/Verifier Name of employer/verifier Full-Time Part-Time Telephone number Address of employer/verifier City (Country) State Physical Location Your actual work address (if different from employer address) Telephone number City (Country) State Supervisor (if different from employer) Name and title Telephone number ZIP Code ZIP Code Work address of supervisor State City (Country) Additional Periods of Activity with this Employer Month/Year To Month/Year Position title Supervisor Month/Year To Month/Year Position title Supervisor Month/Year To Month/Year Position title ZIP Code Supervisor Explanation/Reason for leaving #6 Dates of Employment Month/Year To Month/Year Type of Employment Employment code Position title/Military rank Work hours Full-Time Part-Time Employer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) State Physical Location Your actual work address (if different from employer address) Telephone number City (Country) State Supervisor (if different from employer) Name and title Telephone number ZIP Code ZIP Code Work address of supervisor City (Country) State ZIP Code Enter your Social Security Number before going to the next page American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86 Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 13 EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) Additional Periods of Activity with this Employer Month/Year To Month/Year Position title Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111 Supervisor Month/Year To Month/Year Position title Supervisor Month/Year To Month/Year Position title Supervisor Explanation/Reason for leaving #7 Dates of Employment Month/Year To Month/Year Type of Employment Employment code Position title/Military rank Work hours Employer/Verifier Name of employer/verifier Full-Time Part-Time Telephone number Address of employer/verifier City (Country) State Physical Location Your actual work address (if different from employer address) Telephone number City (Country) State Supervisor (if different from employer) Name and title Telephone number ZIP Code ZIP Code Work address of supervisor State City (Country) Additional Periods of Activity with this Employer Month/Year To Month/Year Position title Supervisor Month/Year To Month/Year Position title Supervisor Month/Year To Month/Year Position title ZIP Code Supervisor Explanation/Reason for leaving PUBLIC BURDEN INFORMATION Public burden reporting for this collection of information averages 20 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. After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification and the attached release(s). Certification 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 have carefully read the foregoing instructions to complete this form. 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 may have a negative effect 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 Date (mm/dd/yyyy) Enter your Social Security Number before going to the next page American LegalNet, Inc. www.FormsWorkFlow.com