Cbp Form 258 – Fill Out and Use This PDF

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

PRIVACY ACT NOTICE FOR FINANCIAL DISCLOSURE REPORT

This information is provided pursuant to Public Law 93-579 (Privacy Act)

AUTHORITY:	Executive Order Number 10450, as amended, reprinted as a Note to 5 U.S.C. 7311; Executive Order Number
	12968; 5 Code of Federal Regulations Parts 732, 736.

PURPOSES AND USES:

This information will be used in national security investigations to ensure that employment, and continued employment, of the under- signed in a national security position is consistent with the interests of the national security. This includes use of the information provid- ed to determine whether the undersigned's financial situation furnishes reason to believe he or she may be subject to coercion, influence, or pressure which may cause him or her to act contrary to the best interests of national security. The financial statement is closely safeguarded in a sealed envelope to ensure that it is not viewed by unauthorized personnel. However, when necessary this information may be furnished to authorized persons for purposes of granting/issuing a security clearance and in a criminal investigation.

EFFECTS OF NONDISCLOSURE:

Disclosure of the information requested is voluntary. However, in the case of an applicant for a sensitive position, refusal to comply will mean that the full field investigation necessary for occupancy of that position cannot be completed, and the applicant will be dropped from consideration for employment in that position. In the case of an employee who is occupying a sensitive position pending comple- tion of the full field investigation, refusal to comply will mean that the investigation cannot be completed and the employee will be reas- signed to a nonsensitive position.

INSTRUCTIONS

The information contained in the attached financial disclosure report is confidential. Please read the following instructions carefully before preparing the statement.

1 Please print plainly or type all answers. Leave no space blank. If the answer is "No" or "None" so indicate in the space provided.

2Use additional sheets where necessary. Place your name and address at the top of each additional sheet. Identify the related question by number. All additional sheets should be securely attached to the disclosure report.

3For the purpose of this statement, wherever the term "immediate family" is used, it means spouse, children or other persons dependent on you, or your spouse, for support.

4Information required in items 2a, 3a, 4a, 5a, 6a, 7a, 8a, 9a, 10a and 11a use F (filer); S (spouse); D (dependent) and O (other individual (s)).

5 Information required in items 6b and 8b use V (vehicle); B (boat); A (airplane) and O (other).

6Information required in item 10b use 2 (second mortgage); A (auto); E (equity); L (line of credit); M (mortgage); O (other loan) and P (personal).

7Information required in item 12a use B (bankruptcy); G (gift); I (inheritance); S (settlements); T (trust); W (winnings) and O (other).

8For the purpose of this statement, information required in Sections 2 through 12 apply not only to the applicant/employee themselves, but to any family member whereby the applicant/employee has access to or control over such assets, etc. Only each individual asset, valued in excess of $1,000 is to be listed. If the asset is part of a group (books, stamps, etc.) the entire collection, if valued over $1,000 should be listed. If assets were acquired by gift or inheritance, list the approximate fair market value, when, how, and from whom acquired. Inheritances/gifts, in excess of $5,000 are to be reported if received within the past seven (7) years.

9Liabilities reflected in Section 11 can be approximate dollar amount owed. Account numbers are not required to be reflected, however, each account/creditor is to be identified by name.

10Upon completion, the financial disclosure report should be placed In a envelope, sealed and returned to the same official who gave you the package which included the blank form. A copy should be retained for your records.

CBP Form 258 (03/06)

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

FINANCIAL DISCLOSURE REPORT

NATIONAL SECURITY POSITIONS

The estimated average burden associated with this collection of information is TWO HOURS per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the reported information. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to CBP, Information Services Group, Washington DC 20229. DO NOT send completed form(s) to this office.

SENSITIVE PERSONAL DATA: After this form is completed, it will contain sensitive personal information which is to be safeguarded pursuant to the Privacy Act of 1974. This information is to be released only to authorized personnel having a need to know for official uses. The completed form should be stored in a locked file cabinet or secured room. When the completed form is no longer needed it should be destroyed by burning or shredding.

PLEASE NOTE: Before completing this form, read the Privacy Act Statement, Sensitive Personal Data and Public Reporting Burden and the instructions.

ANNUAL INCOME, U.S./FOREIGN (For wages & salary, non-taxable and other income, report nothing under $500, round to nearest $1,000. For interest and dividend income, report nothing under $25 and round to the nearest $50.) Describe non-recurring cash income over $10,000 in Section 12.

TOTALS

BANK ACCOUNTS, U.S./FOREIGN (Round total on each line to the nearest $1,000, unless balance is less than $500, then round to the nearest $100).

INVESTMENT ACCOUNTS, U.S./FOREIGN (Round total on each line to the nearest $1,000, unless balance is less than $500, then round to the nearest $100).

OWNED REAL ESTATE, U.S./FOREIGN (Report nothing if price is under $5,000, unless balance is less than $10,000. Do not report capital improvement costs under $10,000, round to the nearest $1,000).

OWNED VEHICLES, BOATS, AIRPLANES, OTHER (Report nothing if purchase price is under $1,000, round purchase price to the nearest $1,000).

CBP Form 258 (03/06)

REAL ESTATE YOU LEASE OR RENT FROM ANOTHER, U.S./FOREIGN (Round monthly payment to the nearest $100).

VEHICLES, BOATS, AIRPLANES, OTHER THAT YOU LEASE FROM ANOTHER (Round monthly payment to the nearest $100)

8a. Codes	8b. Type	8c. Make	8d. Model/Year	8e. Plate or ID	8f. Year Leased	8g. Monthly Lease/Rental
				Number		Payment

OTHER ASSETS, U.S./FOREIGN (Includes self-held securities, antiques, collectibles, jewelry, cash, livestock, trust, etc.. Report name of trust, trustee, and type of assets in 9b. Report nothing under $5,000 for each category round to the nearest $1,000.)

9a. Codes9b. Description9c. U.S./Foreign 9d. Year of Purchase Indicator

MORTGAGES, LOANS (Including installment and personal loans), U.S./FOREIGN (Report nothing with a balance under $500; round balance to the nearest $1,000; round monthly payment to the nearest $100).

10a. Codes	10b. Type of	10c. Name of	10d. U.S./Foreign	10e. Address of Creditor	10f. Original	10g. Year End	10h. Monthly
	Loan	Creditor	Indicator		Balance	Balance	Payment

OTHER LIABILITIES, U.S./FOREIGN (Includes credit accounts, gamishments, judgements, settlements, etc., that you owe. Report nothing with a balance under $500; round balance to the nearest $1,000; round monthly payment to the nearest $100).

11a. Codes	11b. Type of	11c. Name of	11d. U.S./Foreign	11e. Address of Creditor	11f. Year End Balance	11g. Monthly Payment
	Liability	Creditor	Indicator

ADDITIONAL INCOME/BANKRUPTCY - SAFE DEPOSIT BOX/COMMENTS (Provide additional information which you believe to be useful to reviewing officials or requires further explanation).

Safe Deposit Box/Comments:

CERTIFICATION BY PERSON COMPLETING THE FORM: I certify that the entries made by me are true, complete and accurate to the best of my knowledge and belief and are made in good faith. I understand that knowing and willful false statements on this form can be punished by fine or imprisonment or both (See U.S. Code Title 18, Section 1001).

CBP Form 258 (03/06)