GOVERNMENT TRAVEL CHARGE CARD ALTERNATE CREDIT WORTHINESS EVALUATION
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 5701 note, Creditworthiness of Individuals To Be Issued Government Charge Cards; 10 U.S.C. 2784a. Management of travel cards; 41
U.S.C. 101 note, Administrator; DoDI 5154.31, V4, “Commercial Travel Management: DoD Government Charge Card (GTCC) Program.
PRINCIPAL PURPOSE(S): To establish whether applicants or incumbents that are to be issued a government charge card are suitable for the public trust of the government instrument. The information from this form will be used primarily as the basis for evaluating the credit worthiness of an individual in the absence of an authorized credit score. Applicants completing this form may only be eligible for a restricted individually billed travel charge card account.
ROUTINE USE(S): To disclose information to a Federal, State, local, tribal, or foreign agency responsible for investigating, prosecuting, enforcing, implementing, or carrying out a statute, rule, regulation, or order, where an agency becomes aware of a violation or potential violation of civil or criminal law or regulation. Additional routine uses may be found in the applicable system of records notice GSA/GOVT-3, Travel Charge Card Program at: https:// www.federalregister.gov/documents/2013/04/03/2013-07669/privacy-act-of-1974-notice-of-revised-system-of-records
DISCLOSURE: Disclosure is voluntary; however, if you do not provide the requested information, you may not be able to obtain a government travel charge card to perform government official travel duties on behalf of the government.
INSTRUCTIONS
Follow instructions fully and answer all questions or we cannot process your form. Be sure to sign and date the certification statement in Section III. If you have any questions, contact the Agency Program Coordinator who gave you the form or your Component Program Manager.
Purpose of this Form:
Complete this form only if you declined to permit a credit score for an individually billed travel card. Your APC will enter the Component FIPs (https:// nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-87r2.pdf) in item 20.
The Review Process:
The information you provide is considered to be truthful and accurate. You should provide your completed form to your supervisor for review. Individuals unable or unwilling to sign this form will not be issued a government charge card. If your answers reflect no financial risk exists, your form will be maintained along with your application for the government charge card for which you are applying as a result of your official duties. Should information arise at a later date that would cause your current answers to be incorrect, you may revise and resubmit the form. Any information that indicates that your responses are not accurate or truthful may result in administrative action.
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. You must sign and date, in black ink, the original and each copy you submit.
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.Any changes 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 their intent.
4.All telephone numbers must include area codes.
5.All dates provided on this form must be in Year/Month/Day (YYYYMMDD) format.
6.If the address is outside of the United States, please indicate the country.
Final Determination on Your Eligibility:
Final determination on your eligibility for credit worthiness and form acknowledgment is the responsibility of your commander/supervisor. The commander/ supervisor acknowledges the need for a travel card and does not validate the financial responses provided.However, it is DoD policy that failure to agree to a credit score or self-certify to your creditworthiness is sufficient reason to deny issuance of any such card.
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 that may result in fines of up to $10,000 and/or 5 years imprisonment, or both. In addition, Federal agencies usually remove from their employment, 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. Because the position you are in is considered necessary to require use of a government charge card, your trustworthiness and creditworthiness are important considerations in determining your eligibility for retention of a government charge card.
