Electronic Personnel Questionnaire Form – Fill Out and Use This PDF

Updated 09/24/2002

Revised 07/13/2005

ELECTRONIC PERSONNEL

SECURITY QUESTIONNAIRE

SF86 WORKSHEET

This document is meant to be a detailed “Check List” in preparation for completing the SF86 on the Electronic Questionnaires for Investigations Processing (e-QIP). This is not a substitute for the actual SF86. DO NOT send this document to the Defense Security Service. Please see the enclose instructions regarding e-QIP.

Keep the following in mind when completing the SF86:

•Indicate Unk (Unknown) if names are ABSOLUTELY irretrievable.

Module 1: PERSONAL INFORMATION

Name: First: ______________________ Middle: _______________ Last: _____________________

Suffix (i.e.: II, III, or Jr.)*: _________________ SSN: __________________________

Birth Date: ________________________ (YYYY/MM/DD)

Maiden name (if applicable): First: ________________ Middle: __________ Last: ________________

Module 2: OTHER NAMES USED

Have you ever used another name: (Y / N)

If yes, FROM: _________________ To: _________________ (YYYY/MM/DD)

Name Used (Include first, middle, and last names):

_________________________________________________

Module 3: CITIZENSHIP

What is your current citizenship status? (SELECT ONE): (1) US Citizen (2) Not a US Citizen

*Can be left blank

E-QIP SF86 WORKSHEET

Follow Path (1) or (2) depending on your answer. Answer questions and follow arrows/directions as appropriate.

(1)US Citizen (You were either: born in the USA; born in a US Territory/Possession; Born Abroad of US Parents; or Naturalized)

Enter Mother’s Maiden Name: _________________________________________________

FirstMiddle Last

Were you born in the US (US Citizen) or in a US Territory/Possession (US National)? (Y / N) If No, follow arrow to the next question…

If Yes, answer the following:

Are you now or were you a dual citizen of the US and another county? If No, Proceed to Module 4, Residences

If Yes, answer the following:

Enter the name of the country where you hold/held dual citizenship in addition to the United States: ______________________. Go to Module 4, Residences

Where you born abroad of US parents? (Y / N)

If No, you have either a Naturalization or Citizenship Certificate. Follow arrow… If Yes, answer the following:

Citizenship Certificate Number: ______________________

Issue Date: ___________________ (If none, enter Form 240 Date)

City: ________________________ (If none, enter N/A)

State: ________________________ (If none, enter DC)

State Dept. Form 240 Date: __________________________ (YYYY/MM/DD)

Proceed to question immediately below (US passport)…

Do you currently hold or did you previously hold a US passport? (Y / N)

If No, follow arrow to the next question…

If Yes, answer the following:

Passport Number: ________________________

Passport Issue Date: ______________________ (YYYY/MM/DD)

Proceed to question directly below (Dual Citizenship)…

Are you now or were you a dual citizen of the US and another county? (Y / N)

If No, proceed to Module 4, Residences

If Yes, answer the following:

Enter the name of the country where you hold/held dual citizenship in addition to the United States: ______________________________.

Go to Module 4, Residences

Provide the following information:

Naturalization or Citizenship Certificate Number: ___________________

E-QIP SF86 WORKSHEET

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Person who knew you at this address: (Include first, middle, and last names): _____________________________

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Telephone Number: __________________________________________________

(2) Your NEXT ADDRESS:

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(Complete only if residence was within the last five years): Person who knew you at this address

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Telephone Number: __________________________________________________

E-QIP SF86 WORKSHEET

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Telephone Number: ________________________________________________________________

(5) Your NEXT ADDRESS:

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(Complete only if residence was within the last five years): Person who knew you at this address

______________________________

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Telephone Number: _______________________________________________________

(6) Your NEXT ADDRESS:

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

E-QIP SF86 WORKSHEET

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(Complete only if residence was within the last five years): Person who knew you at this address

______________________________

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Telephone Number: _______________________________________________________

(9) Your NEXT ADDRESS:

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(Complete only if residence was within the last five years): Person who knew you at this address

______________________________

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

E-QIP SF86 WORKSHEET

Telephone Number: _______________________________________________________

(10) Your NEXT ADDRESS:

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the residence hard to find? (Y / N) If yes…

Explain: _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(Complete only if residence was within the last five years): Person who knew you at this address

______________________________

FROM: _____________ TO: ______________ (YYYY/MM/DD)

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Telephone Number: _______________________________________________________

Module 5: WHERE YOU WENT TO SCHOOL

Option 1: Did you attend school, beyond Jr. High, within the last 5 years? (Y / N)

If “NO,” go to Option 2, below…

If “YES,” answer the following…

FROM: _______________________ To: ______________________

Type of education? (Pick One)

1.High School

2.College/University/Military College

3.Vocational/Technical/Trade

School Name: _________________________________________________

Degree/Diploma/Other: __________________________________________

E-QIP SF86 WORKSHEET

Award Date: ___________________________________________________

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Person who knew you at above school (ONLY if the education occurred w/in the last 3 years). The reference

should not be a spouse, former spouse, or other relative.

Full Name (Include first, middle, and last names): __________________________________________________

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Phone: _______________________________________________________________________

Option 2: If you answered “no” to Option 1 above, review the following…

Have you attended school beyond high school? (Y / N)

•Note: If all education occurred more than 5 years, list most recent beyond high school, regardless of date.

If Yes, answer the following…

FROM: _______________________ To: ______________________

Type of Education? (Pick One)

1.College/University/Military College

2.Vocational/Technical/Trade

School Name: _________________________________________________

Degree/Diploma/other: __________________________________________

Award Date: ___________________________________________________

ADDRESS LINE 1: ________________________________________________________________

ADDRESS LINE 2*: _______________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

E-QIP SF86 WORKSHEET

Module 6: YOUR EMPLOYMENT ACTIVITIES

(Provide 10 years of employment info. You should list all full-time work, part-time work, military service, temporary military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. All periods of unemployment require a verifying individual. The individual should not be a spouse, former spouse, or other relative.)

(1)Your CURRENT EMPLOYMENT:

FROM: ______________________ To: PRESENT (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): Fort Worth, TX 76137 USA

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (No). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

E-QIP SF86 WORKSHEET

(2)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

(3)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

E-QIP SF86 WORKSHEET

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

(4)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

E-QIP SF86 WORKSHEET

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

(5)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

E-QIP SF86 WORKSHEET

(6)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

(7)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

E-QIP SF86 WORKSHEET

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

(8)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

E-QIP SF86 WORKSHEET

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

(9)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

E-QIP SF86 WORKSHEET

(10)Your PREVIOUS EMPLOYMENT:

FROM: _____________ TO: ____________ (YYYY/MM/DD)

TYPE OF EMPLOYMENT (Select one):

BRANCH: (If Military): ____________________________________________

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the work site address different from the employer address? (Yes). If yes…

SITE ADDRESS LINE 1: ___________________________________________________________

SITE ADDRESS LINE 2*: __________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Module 6: (Employment cont.) Were you in federal civil service prior to the last 10 years? (Y/N)

•Note: Enter all Federal Employment prior to the last 10 years (Do NOT list if already reported above!).

FROM: _____________ TO: ____________ (YYYY/MM/DD)

EMPLOYER NAME: _________________________ Employer Phone: ___________________

Your position/title: ______________________________

JOB ADDRESS LINE 1: ____________________________________________________________

JOB ADDRESS LINE 2*: ___________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

E-QIP SF86 WORKSHEET

Supervisor’s full name (Include first, middle, and last names): ________________________________________

Supervisor’s phone: ______________________

Is the employer’s address different from the job location address? (Y / N). If yes…

Employer’s ADDRESS LINE 1: ______________________________________________________

Employer’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ________________________________________________

Is the supervisor’s address different from the job location address? (Y / N). If yes…

Supervisor’s ADDRESS LINE 1: _____________________________________________________

Supervisor’s ADDRESS LINE 2*: _____________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

Module 7: PEOPLE WHO KNOW YOU WELL

•Note: Provide three people living in the USA who know you well. The references should not be a spouse, former spouse, or other relative. Try not to list someone listed elsewhere on your form. The reference’s combined association with you must cover the last SEVEN yearS OF COMBINED ASSOCIATION.

(1)FROM: ________________ TO: ___________________ (YYYY/MM/DD)

Name: First: ___________________ Middle: _________ Last: ____________________________

Address (Home or Work?): ______________________________________________________________

City/State/ZIP: ____________________________________________________________________

Phone: ______________________________________ Day / Evening (circle one).

(2)FROM: ________________ TO: ___________________ (YYYY/MM/DD)

Name: First: ___________________ Middle: _________ Last: ____________________________

Address (Home or Work?): ______________________________________________________________

City/State/ZIP: ____________________________________________________________________

Phone: ______________________________________ Day / Evening (circle one).

(3)FROM: ________________ TO: ___________________ (YYYY/MM/DD)

Name: First: ___________________ Middle: _________ Last: ____________________________

Address (Home or Work?): ______________________________________________________________

City/State/ZIP: ____________________________________________________________________

Phone: ______________________________________ Day / Evening (circle one).

E-QIP SF86 WORKSHEET

Divorce Date: _____________ (YYYY/MM/DD)

City/State/Country of Divorce: _______________________________________________________

Former Spouse’s Address/Phone # (Omit if former spouse is deceased): ________________________________

_________________________________________________________________________________

Former Spouse’s Citizenship: _________________________

Other marriages? Use the Continuation Space at the end of this worksheet.

Module 9: YOUR RELATIVES AND ASSOCIATES

Entry List Options:

1)Include only foreign national relatives not listed in 1-16 with whom you or your spouse are bound by affection, obligation or close and continuing contact.

2)Include only foreign national associates with whom you or your spouse are bound by affection, obligation or close and continuing contact.

(1)RELATIONSHIP: Mother - Mandatory Entry (If you were adopted, you should list your adoptive mother. If you do not know who your biological parents are, you may enter “UNK” in the first name and omit the remaining data. Using “UNK” is applicable for other relatives on the SF86.)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if your mother is living, was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

ΩIf your mother was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.

E-QIP SF86 WORKSHEET

(2)RELATIONSHIP: Father - Mandatory Entry (If you were adopted, you should list your adoptive father. If you do not know who your biological parents are, you may enter “UNK” in the first name and omit the remaining data. Using “UNK” is applicable for other relatives on the SF86.)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if your father is living, was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

(3) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.

E-QIP SF86 WORKSHEET

(4) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

(5) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.

E-QIP SF86 WORKSHEET

(6) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

(7) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.

E-QIP SF86 WORKSHEET

(8) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

(9) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)

Current Name: ________________________________________________________________

First Middle Lastsuffix*

Birth Date: __________________ Country of Birth: ____________________________

(YYYY/MM/DD)

Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________

Address Line 2*: _________________________________________________________________

CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________

CitizenshipΩ: _______________________

The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:

ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.

E-QIP SF86 WORKSHEET

Module 10: CITIZENSHIP OF YOUR RELATIVES AND ASSOCIATES

If you currently have a spouse-like relationship with someone who is a U.S. citizen NOT by birth, or who is an alien residing in the United States, you should provide the following basic information about that person.

Current Name: ________________________________________________________________

Module 11: YOUR MILITARY HISTORY

Have you ever been in the military? (Y / N) If yes...

List all of your military service below, including service in the Reserve, National Guard, U.S. Merchant Marine and Foreign Military Service. Start with the most recent period of service and work backward. If you had a break in service, each separate period should be listed. Please include a copy(s) of your DD214 with this questionnaire.

Status: ___________________ (Active, Active Reserve, Inactive)

State: ______________ (For National Guard) Service Number: _________________ (i.e. SSN)

Module 12: YOUR FOREIGN ACTIVITIES - PROPERTY

Do you have any foreign property, business connections, or financial interests? (Y / N) If yes… FROM: __________________ TO: _________________ (YYYY/MM/DD)

FIRM NAME/COUNTRY: ____________________________________________

REMARKS: ______________________________________________________________________

_________________________________________________________________________________

Module 13: YOUR FOREIGN ACTIVITIES - EMPLOYMENT

Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm or agency? (Y / N) If yes…

FROM: _____________________ TO: ___________________ (YYYY/MM/DD)

Firm and/or Government/ Country: ____________________________________________________

E-QIP SF86 WORKSHEET

REMARKS: ______________________________________________________________________

_________________________________________________________________________________

Module 14: YOUR FOREIGN ACTIVITIES - CONTACT WITH FOREIGN GOVERNMENT

Have you ever had any conduct with a foreign government, its establishments (embassies or consulates), or it’s representatives, whether inside or outside the U.S., other than on official U.S. Government business? (Does not include routine visa applications and border crossing contacts.) (Y / N) If yes…

FROM: _____________________ TO: _________________ (YYYY/MM/DD)

Firm and/or Government/ Country: ____________________________________________________

REMARKS: ______________________________________________________________________

_________________________________________________________________________________

Module 15: YOUR FOREIGN ACTIVITIES - PASSPORT

In the last 7 years, have you had an active passport that was issued by a foreign government? If yes…

Issue Date: __________________ (YYYY/MM/DD) Expiration Date: ________________ (YYYY/MM/DD)

Issuing Country: __________________________________

REMARKS: ______________________________________________________________________

_________________________________________________________________________________

Module 16: FOREIGN COUNTRIES YOU HAVE VISITED

Have you traveled outside the United States on other than official U.S. Government orders in the last 7 years? (Travel as a dependent or contractor must be listed.) Do not repeat travel covered in

modules 4, 5, and 6. If yes…

FROM: _______________ TO: _________________ (YYYY/MM/DD)

Purpose of Visit (Select One): Pleasure, Education, Business or Other

Country visited: ____________________

Other countries visited during this trip? (If Yes, indicate Purpose and Country Visited): __________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Additional Entries? Use the Continuation Space at the end of this worksheet.

E-QIP SF86 WORKSHEET

Module 17: YOUR MILITARY RECORD

Have you ever received other than an honorable discharge from the military? (Y / N) If yes…

Discharge Date:

Module 18: YOUR SELECTIVE SERVICE RECORD

If you are a male born after December 31, 1959, enter your Selective Service Registration Number: _______________________. (For Info. CALL 1-847-688-6888 or visit www.sss.gov.)

If you have not registered with the Selective Service System, provide reason for legal exemption:

________________________________________________________________________________

________________________________________________________________________________

Module 19: YOUR MEDICAL RECORD

In the last 7 years, have you consulted a mental health professional (psychiatrist, psychologist, counselor, etc.) or have you consulted with another health care provider about a mental health related condition? (Y / N) If No, proceed to Module 20. If Yes, answer the following…

Did the mental health related consultation (s) involve only marital, family, or grief counseling not related to violence by you? (Y / N) If Yes, proceed to Module 20. If No, answer the following…

Provide the following information about the Therapist/Doctor:

Name: (First) ___________________ Middle: _________ Last: ____________________________

Address: _________________________________________________________________________

City/State/Country/ZIP: _____________________________________________________________

Dates of Care: FROM: ________________ TO: ___________________ (YYYY/MM/DD)

Other consultations? Use the Continuation Space at the end of this worksheet.

Module 20: YOUR EMPLOYMENT RECORD

Has any of the following happened to you in the last 10 years? (Y / N)

1.Fired from a job

2.Quit a job after being told you’d been fired

3.Left a job by mutual agreement following allegations of misconduct

4.Left a job by mutual agreement following allegations of unsatisfactory performance

5.Left a job for other reasons under unfavorable circumstances

If Yes, Provide: Employer(s) Name(s): ________________________________________________

E-QIP SF86 WORKSHEET

Date(s) of Employment(s): FROM: _________________ TO: __________________ (YYYY/MM/DD)

Type of Termination (select from list above): _____________________________________________

_______________________________________________________________________________

Module 21: YOUR POLICE RECORD - FELONY OFFENSES

Have you ever been charged with or convicted of any felony offense? ⊗ (Y / N) If Yes, provide the following:

Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________

Action: ___________________________ Authority/Court: _______________________________

City/State/Zip: ______________________________________ Country: ______________________

Module 22: YOUR POLICE RECORD - FIREARMS/EXPLOSIVES OFFENSES

Have you ever been charged with or convicted of a firearms or explosives offense?⊗ (Y / N) If Yes, provide the following:

Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________

Action: ___________________________ Authority/Court: _______________________________

City/State/Zip: ______________________________________ Country: ______________________

Module 23: YOUR POLICE RECORD - PENDING CHARGES

Are there currently any charges pending against you for any offense?⊗ (Y / N) If Yes, provide the following:

Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________

Action: ___________________________ Authority/Court: _______________________________

City/State/Zip: ______________________________________ Country: ______________________

Module 24: YOUR POLICE RECORD - ALCOHOL/DRUG OFFENSES

Have you ever been charged with or convicted of any offense(s) to alcohol or drugs? ⊗ (Y / N) If Yes, provide the following:

Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________

Action: ___________________________ Authority/Court: _______________________________

City/State/Zip: ______________________________________ Country: ______________________

⊗For these items, report information regardless of whether the record in your case has been "sealed" or otherwise stricken from the record. The single exception to this requirement is for certain convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 360.

E-QIP SF86 WORKSHEET

Module 33: YOUR FINANCIAL RECORD - BANKRUPTCY

In the last 7 years, have you filed a petition under any chapter of the bankruptcy code (to include Chapter 13)? (Y / N) If Yes, provide the following:

File Date: ______________ Name Action Occurred Under: ________________________________

Amount: _____________ Court Name: _______________________________________________

City/State/Zip: ____________________________________________________________________

Module 34: YOUR FINANCIAL RECORD - WAGE GARNISHMENTS

In the last 7 years, have you had your wages garnished for any reason? (Y / N) If Yes, provide the following:

Execution Date: ___________ Name Action Occurred Under: ______________________________

Amount: _____________ Court/Agency Name: ________________________________________

Address/City/State/Zip: _____________________________________________________________

Module 35: YOUR FINANCIAL RECORD - REPOSSESSIONS

In the last 7 years, have you had any property repossessed for any reason? (Y / N) If Yes, provide the following:

Repossession Date: ___________ Name Action Occurred Under: ___________________________

Amount: _____________ Agency Name: _____________________________________________

Address/City/State/Zip: _____________________________________________________________

Module 36: YOUR FINANCIAL RECORD - TAX LIEN

In the last 7 years, have you had a lien placed against your property for failing to pay taxes and other debts? (Y / N) If Yes, provide the following:

Lien Date: _____________ Name Action Occurred Under: ________________________________

Amount: _____________ Court/Agency Name: ________________________________________

City/State/Zip: ____________________________________________________________________

Module 37: YOUR FINANCIAL RECORD - UNPAID JUDGEMENTS

In the last 7 years, have you had any judgments against you that have not been paid? (Y / N) If Yes, provide the following:

Judgment Date: __________ Name Action Occurred Under: _______________________________

Amount: _____________ Court Name: _______________________________________________

E-QIP SF86 WORKSHEET

City/State/Zip: ____________________________________________________________________

Module 38: YOUR FINANCIAL DELINQUENCIES - 180 DAYS

In the last 7 years, have you been over 180-day’s delinquent on any debt (s)? (Y / N) If Yes, provide the following:

INCURRED DATE: ________________ SATISFIED DATE: ________________ (YYYY/MM/DD)

Amount: ___________________ Type of Loan/Obligation: _______________________________

Account Number: __________________________________________________________________

Creditor/Obligee Name: _____________________________________________________________

Address/City/State/Zip: _____________________________________________________________

Module 39: YOUR FINANCIAL DELINQUENCIES - 90 DAYS

Are you currently over 90 days delinquent on any debt(s)? (Y / N) If Yes, provide the following: INCURRED DATE: ________________ SATISFIED DATE: ________________ (YYYY/MM/DD)

Amount: ___________________ Type of Loan/Obligation: _______________________________

Account Number: __________________________________________________________________

Creditor/Obligee Name: _____________________________________________________________

Address/City/State/Zip: _____________________________________________________________

Module 40: PUBLIC RECORD CIVIL COURT ACTIONS

In the last 7 years, have you been a party to any public record civil court actions not listed elsewhere on this form? (Y / N) If Yes, provide the following:

DATE: _____________ (YYYY/MM/DD) Nature of Action: __________________________________

Result of Action: ____________________________ Court Name: ___________________________

County: _________________________ City/State/Country/Zip: ____________________________

________________________________ Party To This Action: _____________________________

Module 41: YOUR ASSOCIATION RECORD - MEMBERSHIP

Have you ever been an officer or a member or made a contribution to an organization dedicated to the violent overthrow of the United States Government and which engages in illegal activities to that end, knowing that the organization engages in such activities with the specific intent to further such activities? (Y / N) If Yes, provide details of your association:

Comments: _______________________________________________________________________

_________________________________________________________________________________

E-QIP SF86 WORKSHEET

Module 42: YOUR ASSOCIATION RECORD - ACTIVITIES

Have you ever knowingly engaged in any acts or activities designed to overthrow the United States Government by force? (Y / N) If Yes, provide details of such acts or activities:

Comments: _______________________________________________________________________

_________________________________________________________________________________

Module 43: GENERAL REMARKS

Do you have any additional remarks to enter in your application? If Yes, provide comments:

Comments: _______________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Continuation Space (If more space is needed, use blank sheet(s) of paper): ___________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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