Sf85P Form Fillable PDF Details

Filling out the Standard Form 85P, revised in December 2017 by the U.S. Office of Personnel Management, is a critical step for individuals being considered for, or retaining, public trust positions within the federal government. This meticulous process, regulated under 5 CFR Parts 731, 732, and 736, requires applicants to provide complete and truthful answers to facilitate a thorough background investigation. Its purpose extends to determining eligibility not only for federal employment but also for contract roles and access to federal facilities or information systems, highlighting its significance in safeguarding national interests. Failure to provide accurate information can lead to severe implications, including loss of employment or legal action, emphasizing the form's role in the vetting process. Moreover, the form initiates a comprehensive review that encompasses various aspects of an individual's background such as financial stability, character, and loyalty to the United States. It underlines the importance of transparency, accuracy, and cooperation from applicants, serving as a cornerstone for national security and integrity within public trust positions. Applicants are advised to closely adhere to the instructions and to understand that this form, along with their responses, becomes a permanent artifact in their employment record, warranting careful and honest disclosure of information.

QuestionAnswer
Form NameSf85P Form Fillable
Form Length95 pages
Fillable?Yes
Fillable fields2702
Avg. time to fill out37 min 36 sec
Other namessf85, sf85p form, sf85 sf85p usps, sf85 sf85p

Form Preview Example

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.

All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties for inaccurate or false statements are discussed below. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully could result in an adverse personnel action against you, including loss of employment; with respect to Sections 21, 25, and 27, however, neither your truthful responses nor information derived from those responses will be used as evidence against you in a subsequent criminal proceeding.

Note: If you complete the SF 85P, an Authorization for Release of Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) will be provided to you only in the event information arises in an investigation that requires further inquiry for resolution, and only to resolve such issues. This release authorizes an investigator to ask your health practitioner(s) only the questions specified on the release concerning mental health consultations of which the practitioner might be aware. If you are completing the SF 85P with the supplemental SF 85P-S, this release will be provided to you if you respond "yes" to the question regarding Your Medical Record. You may also be asked to complete a specific release if more detailed information is needed from your provider.

Purpose of this Form

This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, public trust positions as defined in 5 CFR

731.This form may also be used by agencies in determining whether a subject performing work for, or on behalf of, the Government under a contract should be deemed eligible for logical or physical access when duties to be performed by an employee of a contractor are equivalent to the duties performed by an employee in a public trust position. For applicants, this form is to be used only after a conditional offer of employment has been made. This form is not to be used for National Security sensitive positions.

Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely affect your eligibility for a public trust position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information provided be true and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and duties, and consistency with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for a public trust position, or your ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your eligibility for physical and logical access to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect your employment prospects and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.

This form is a permanent document that may be used as the basis for future investigations, suitability or fitness for Federal employment, fitness for contract employment, or eligibility for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your responses to previous SF 85P questionnaires.

The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, social security number, and date and place of birth.

Authority to Request this Information

Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders, 13764, 10577, 13467, and 13488; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations (CFR), and Federal information processing standards.

Your Social Security Number (SSN) is needed to identify records unique to you. 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, as amended by EO 13478.

Your spouse's SSN is needed solely to allow the investigative service provider to make inquiries regarding whether there is relevant conduct on your part as a result of your relationship with your spouse. Your spouse is not subject of the investigation.

The Investigative Process

Background investigations for public trust positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation. The investigation may extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although you may have previously indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation, which can adversely affect your eligibility for a public trust position or your ability to obtain Federal or contract employment. To avoid such delays, you must request that the consumer reporting agencies lift the freeze in these instances.

In addition to the questions on this form, inquiry also is made about your adherence to security requirements your honesty and integrity, falsification, misrepresentation, and any other behavior, activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal.

After a suitability /fitness determination is made, you may also be subject to continuous vetting which may include periodic reinvestigations to ensure your continuing suitability for employment.

Your Personal Interview

Some investigations will include an interview with you as a routine part of the investigative process. The investigator may ask you to explain your answers to any question on this form. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often assists in completing your investigation. It is imperative that the interview be conducted as soon as possible after you are contacted. Postponements will delay the processing of your investigation, and declining to be interviewed may result in your investigation being delayed or canceled.

For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to verify your identity, as instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention. These matters include (a) alien registration or naturalization documents; (b) delinquent loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support, alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court records.

Page 1

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Instructions for Completing this Form

1.Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form. You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.

2.All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise noted.

3.Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country drop down feature.

4.When entering a U.S. address or location, select the state or territory from the "States" drop down list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" drop down list and leave the "State" field blank.

5.The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.

6.For telephone numbers in the U.S., ensure that the area code is included.

7.All dates provided in this form must be in Month/Day/ Year or Month/Year

format. Use numbers (01-12) to indicate months. For example, July 29,1968, should be written as 07/29/1968. If you are unable to report an exact date, approximate or estimate the date to the best of your ability,and indicate this by checking the “Estimate” box.

Final Determination on Your Suitability

Final determination on your suitability for a public trust position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, or sexual orientation when making determinations of suitability for a public trust position.

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 which may result in fines and/or up to five (5) years imprisonment. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you provide on this form and to make your comments part of the record.

Disclosure Information

The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. The office that gave you this form will provide you a copy of its routine uses.

Office of Personnel Management (OPM) Routine Uses

The Privacy Act routine uses of agencies conducting or requesting investigations, or with authorized custody over your investigative information, commonly include some or all of the following:

a.To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government or the Government of the District of Columbia having a need to investigate, evaluate, or make a determination regarding loyalty to the United States; qualifications, suitability, or fitness for Government employment or military service; eligibility for logical or physical access to federally-controlled facilities or information systems;eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.

b.To an element of the U.S. Intelligence Community as identified in E.O.12333, as amended, for use in intelligence activities for the purpose of protecting United States national security interests.

c.To any source from which information is requested in the course of an investigation, 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.

d.To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.

e.To an agency, office, or other establishment in the executive, legislative,or judicial branches of the Federal Government in response to its request,in connection with its current employee’s, contractor employee’s, or military member’s retention; loyalty; qualifications, suitability, or fitness for employment; eligibility for logical or physical access to federally-controlled facilities or information systems; eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.

f.To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual. However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from the subject of the investigation.

g.To disclose information to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government.

h.For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative support.

i.To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.

j.To appropriate agencies, entities, and persons when (1) OPM suspects or has confirmed that there has been a breach of the system of records; (2) OPM has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, the agency (including its information systems, programs and operations), the Federal Government,or national security; and (3) the disclosure made to such agencies,entities, and persons is reasonably necessary to assist in connection with OPM’s efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm.

Page 2

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

k.To another Federal agency or Federal entity, when OPM determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the agency (including its information systems,programs and operations), the Federal Government, or national security,resulting from a suspected or confirmed breach.

l.To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, when the Government is a party to the judicial or administrative proceeding. In those cases where the Government is not a party to the proceeding, records may be disclosed if a subpoena has been signed by a judge.

m.To disclose information to the National Archives and Records Administration for use in records management inspections.

n.To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which OPM is authorized to appear, when:

(1)OPM, or any component thereof; or

(2)Any employee of OPM in his or her official capacity; or

(3)Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or

(4)The United States, when OPM determines that litigation is likely to affect OPM or any of its components; is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OPM is deemed by OPM to be relevant and necessary to the litigation, provided, however, that the disclosure is compatible with the purpose for which records were collected.

o.For the Merit Systems Protection Board--To disclose information to officials of the Merit Systems Protection Board or the Office of the Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of OPM rules and regulations, investigations of alleged or possible prohibited personnel practices, and such other functions, e.g., as promulgated in 5U.S.C. 1205 and 1206, or as may be authorized by law.

p.To disclose information to an agency Equal Employment Opportunity(EEO) office or to the Equal Employment Opportunity Commission when requested in connection with investigations into alleged or possible discrimination practices in the Federal sector, or in the processing of a Federal-sector-sector EEO complaint.

q.To disclose information to the Federal Labor Relations Authority or its General Counsel when requested in connection with investigations of allegations of unfair labor practices or matters before the Federal Service Impasses Panel.

r.To another Federal agency’s Office of Inspector General when OPM becomes aware of an indication of misconduct or fraud during the applicant’s submission of the standard forms.

s.To another Federal agency’s Office of Inspector General in connection with its inspection or audit activity of the investigative or adjudicative processes and procedures of its agency as authorized by the Inspector General Act of 1978, as amended, exclusive of requests for civil or criminal law enforcement activities.

t.To a Federal agency or state unemployment compensation office upon its request in order to adjudicate a claim for unemployment compensation benefits when the claim for benefits is made as the result of a qualifications, suitability, fitness, security, identity credential, or access determination.

u.To appropriately cleared individuals in Federal agencies, to determine whether information obtained in the course of processing the background investigation is or should be classified.

v.To the Office of the Director of National Intelligence for inclusion in its Scattered Castles system in order to facilitate reciprocity of background investigations and security clearances within the intelligence community or assist agencies in obtaining information required by the Federal Investigative Standards.

w.To the Director of National Intelligence, or assignee, such information as may be requested and relevant to implement the responsibilities of the Security Executive Agent for personnel security, and pertinent personnel security research and oversight, consistent with law or executive order.

x.To Executive Branch Agency insider threat, counterintelligence, and counter terrorism officials to fulfill their responsibilities under applicable Federal law and policy, including but not limited to E.O. 12333, 13587and the National Insider Threat Policy and Minimum Standards.

y.To the appropriate Federal, State, local, tribal, foreign, or other public authority in the event of a natural or man made disaster. The record will be used to provide leads to assist in locating missing subjects or assist in determining the health and safety of the subject. The record will also be used to assist in identifying victims and locating any surviving next of kin.

z.To Federal, State, and local government agencies, if necessary, to obtain information from them which will assist OPM in its responsibilities as the authorized Investigation Service Provider in conducting studies and analyses in support of evaluating and improving the effectiveness and efficiency of the background investigation methodologies.

aa.To an agency, office, or other establishment in the executive, legislative,or judicial branches of the Federal Government in response to its request, in connection with the classifying of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency’s decision on the matter.

Public Burden Information

Public burden reporting for this collection of information is estimated toaverage155minutesperresponse,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, Attn: OMB Number 3206-0258, 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number, 3206-0258, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Page 3

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

 

LOCATION CODES

Form approved: OMB No. 3206 0258

Alabama

AL

Hawaii

HI

Massachusetts

MA

New Mexico

NM

South Dakota

SD

Alaska

AK

Idaho

ID

Michigan

MI

New York

NY

Tennessee

TN

Arizona

AZ

Illinois

IL

Minnesota

MN

North Carolina

NC

Texas

TX

Arkansas

AR

Indiana

IN

Mississippi

MS

North Dakota

ND

Utah

UT

California

CA

Iowa

IA

Missouri

MO

Ohio

OH

Vermont

VT

Colorado

CO

Kansas

KS

Montana

MT

Oklahoma

OK

Virginia

VA

Connecticut

CT

Kentucky

KY

Nebraska

NE

Oregon

OR

Washington

WA

Delaware

DE

Louisiana

LA

Nevada

NV

Pennsylvania

PA

West Virginia

WV

District of Columbia

DC

Maine

ME

New Hampshire

NH

Rhode Island

RI

Wisconsin

WI

Florida

FL

Maryland

MD

New Jersey

NJ

South Carolina

SC

Wyoming

WY

Georgia

GA

 

 

 

 

 

 

 

 

American Samoa

AS

Johnson Atoll

JQ

Midway Islands

MQ

Palmyra Atoll

LQ

Wake Island

WQ

Baker Island

FQ

Kingman Reef

KQ

Navassa Island

BQ

Puerto Rico

PR

APO/FPO America

AA

Guam

GU

Marshall Islands

MH

Northern Mariana Islands

MP

Virgin Islands, United

VI

APO/FPO Europe

AE

Howland Island

HQ

Micronesia, Federated

FM

Palau

PW

States

 

APO/FPO Pacific

AP

Jarvis Island

DQ

States

 

 

 

 

 

 

 

AGENCY USE BLOCK "AUB"

Investigating agency user only

Codes: (FIPC CODES)

Case Number:

FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.

A Type of investigation

B Extra coverage/Advanced results

C Risk level

 

 

 

 

 

 

 

 

 

 

E Nature of action code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F Date of action (Month/Day/Year)

G Geographic location

H Position code

 

I Position title

 

 

 

J SON (Submitting Office Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K Location of Official Personnel Folder

 

None

 

 

At SON

 

 

Other

 

Other address/Web address of e-OPF

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NPRC

 

 

e-OPF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L SOI (Security Office Identifier)

M Location of Security Folder

 

 

None

 

 

At SOI

 

 

 

e-OPF

Other address/Web address of e-OPF

Zip Code

 

 

 

 

 

 

 

 

NPI

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N IPAC

 

O TAS

 

 

 

 

 

P Obligating document number

Q BETC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R Accounting data and/or Agency case number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S Investigative requirement

 

 

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reinvestigation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRequesting Official - Name

Title

Signature

Email address

 

 

 

Telephone number (Include Ext.)

 

 

Date (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U Secondary Requesting Official - Name

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email address

Telephone number (Include Ext.)

V Applicant affiliation

 

FED CIV

 

 

 

CON

 

 

 

 

 

 

MIL

 

 

 

Other

W Deployment/PCS (if imminent)

 

 

 

 

 

 

 

 

 

 

From (Month/Day/Year)

Est.

To (Month/Day/Year)

Estimated Permanent Relocation

Reason(s) for temporary duty assignment or PCS

Point of contact at location

 

Telephone number (Include Ext.)

 

Address/Unit/Duty location (Include City or Post Name)

 

 

 

 

 

 

 

Agency Special Instructions for the Investigative Service Provider.

Commercial and Government Entity (CAGE) Code

Contract Number

Page 4

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.

I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the

YES

NO

penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal

 

 

Service.

 

 

Section 1 - Full Name

Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last Name

First Name

Middle Name

Suffix

Section 2 - Date of Birth

Provide your date of birth. (Month/Day/Year)

Est.

Section 3 - Place of Birth

Provide your place of birth.

 

 

 

City

County

State

Country (Required)

Section 4 - Social Security Number

Provide your U.S. Social Security Number.

Not applicable

Section 5 - Other Names Used

Have you used any other names?

YES

NO (If NO, proceed to Section 6)

Complete the following if you have responded 'Yes' to having used other names.

Provide your other name(s) used and the period of time you used it/them [for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Provide other name used

 

 

 

 

 

 

 

 

 

 

#1 Last name

 

 

 

First name

 

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (Month/Year)

 

To (Month/Year)

Present

Maiden name?

Provide the reason(s) why the name changed

 

 

 

 

 

 

 

 

 

 

 

Est.

 

Est.

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide other name used

 

 

 

 

 

 

 

 

 

 

#2 Last name

 

 

 

First name

 

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (Month/Year)

To (Month/Year)

Est.

Present Est.

Maiden name?

Provide the reason(s) why the name changed

 

 

YES

NO

 

 

 

 

Provide other name used

 

 

 

#3 Last name

First name

Middle name

Suffix

From (Month/Year)

To (Month/Year)

Est.

Present Est.

Maiden name?

Provide the reason(s) why the name changed

YES

NO

 

 

 

 

 

Provide other name used

 

 

 

#4 Last name

First name

Middle name

Suffix

From (Month/Year)

To (Month/Year)

Est.

Present Est.

Maiden name?

Provide the reason(s) why the name changed

YES

NO

 

 

 

 

 

Section 6 - Your Identifying Information

Provide your identifying information.

Height

Weight (in pounds)

Hair color

(feet) (inches)

Eye color

Sex

Female

Male

Enter your Social Security Number before going to the next page

Page 5

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 7 - Your Contact Information

Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background investigation.

Home e-mail address

 

 

 

 

Work e-mail address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

Day

 

International or DSN phone number

Day

 

International or DSN phone number

Day

 

 

 

Home telephone number Extension

Night

 

Work telephone number

 

Extension

Night

 

Mobile/Cell telephone number

Extension

Night

 

 

 

 

Both

 

 

 

 

 

Both

 

 

 

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 8 - U.S. Passport Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you possess a U.S. passport (current or expired)?

 

 

 

 

 

 

 

 

 

YES

NO (If NO, proceed to Section 9)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following information for the most recent U.S. passport you currently possess.

 

Click HERE for U.S. State Department passport help

 

Passport number

Issue date (Month/Day/Year) Expiration date (Month/Day/Year)

 

 

 

 

 

 

Est.

 

 

 

Est.

 

http://travel.state.gov/passport

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which passport was first issued.

 

 

 

 

 

 

 

 

 

Last name

 

 

 

 

First name

 

 

Middle name

Suffix

 

 

Section 9 - Citizenship

Select the box that reflects your current citizenship status.

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.

(Proceed to Section 10)

I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.

(Complete 9.1)

I am a derived U.S. citizen. (Complete 9.3)

I am not a U.S. citizen. (Complete 9.4)

I am a naturalized U.S. citizen. (Complete 9.2)

9.1Complete the following if you answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country. Provide type of documentation of U.S. citizen born abroad.

FS 240

DS 1350

FS 545

Other (Provide explanation)

 

 

 

 

 

 

 

 

Provide document number for U.S. citizen born abroad.

Provide the date the document was issued. (Month/Day/Year)

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

Provide the name in which document was issued.

 

 

 

 

Last name

 

 

First name

 

Middle name

 

Suffix

 

 

 

 

 

Provide your citizenship certificate number.

Provide the date the certificate was issued. (Month/Day/Year)

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

Provide the place of issuance.

 

 

 

 

 

 

City

 

 

State

Country

 

 

 

 

 

 

 

 

Provide the name in which the certificate was issued.

 

 

 

 

Last name

 

 

First name

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

Were you born on a U.S. military installation?

Provide the name of the base.

 

 

YES

NO (If NO, proceed to Section 10)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 6

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 9 - Citizenship - (CONTINUED)

Form approved: OMB No. 3206 0258

9.2Complete the following if you answered that you are a naturalized U.S. citizen.

Provide the date of entry into the U.S.

(Month/Day/Year)

Est.

Provide the location of entry into the U.S.

 

City

State

Provide country(ies) of prior citizenship.

 

#1 Country

#2 Country

Do/did you have a U.S. alien registration number?

YES

NO

Provide your U.S. alien registration number on Certificate of Naturalization - utilize USCIS, CIS, or INS registration, I-551, I-766.

Provide your Certificate of Naturalization number (N550 or N570). Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)

Est.

Provide the name of the court that issued the Certificate of Naturalization.

Provide the address of the court that issued the Certificate of Naturalization.

 

Street

City

State

Zip Code

 

Provide the name in which the Certificate of Naturalization was issued.

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

Provide the basis of naturalization.

 

 

 

 

 

 

 

 

 

 

Based on my own individual naturalization application

 

 

 

 

 

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.3 Complete the following if you answered that you are a derived U.S. citizen.

 

 

 

 

 

 

 

 

 

 

 

Provide your alien registration number (on Certificate of

Provide your Permanent Resident Card

Provide your Certificate of Citizenship

 

Citizenship — utilize USCIS, CIS or INS registration number)

number (I-551)

number (N560 or N561)

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which the document was issued.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the date document was issued

(Month/Day/Year)

Provide the basis of derived citizenship.

 

 

 

 

 

 

Est.

 

By operation of law through my U.S. citizen parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

9.4Complete the following if you answered that you are not a U.S. citizen.

Provide your residence status.

Provide your date of entry in the U.S. (Month/Day/Year)

 

Est.

 

 

Provide your country(ies) of citizenship.

#1 Country

#2 Country

Provide your place of entry in the U.S.

 

City

State

Provide your alien registration number (I-551, I-766)

Provide document expiration

date (I-766 ONLY) (Month/Day/Year)

Est.

Provide type of document issued. (I-94, U.S. Visa - red foil number, I-20, DS-2019, etc.)

 

 

 

I-94

U.S. Visa (red foil number)

I-20

DS-2019

 

 

 

Other

(Provide explanation)

 

 

 

 

 

 

 

 

 

Provide document number.

Provide the date document was issued (Month/Day/Year)

 

Provide document expiration date. (Month/Day/Year)

 

 

 

Est.

 

 

Est.

 

 

 

 

 

Provide the name in which the document was issued.

 

 

 

Last name

 

 

First name

Middle name

Suffix

Enter your Social Security Number before going to the next page

Page 7

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information

10.1 Do you now or have you EVER held dual/multiple citizenships?

YES

NO (If NO, proceed to 10.2)

 

 

 

Complete the following if you answered 'Yes' to having EVER held dual/multiple citizenships.

 

 

 

 

 

Entry #1

 

 

Provide country of citizenship.

How did you acquire this non-U.S. citizenship you now have or previously had?

During what period of time did you hold citizenship with this country? (Provide the date range that you held this citizenship, beginning with the date it was acquired through its termination or "Present," whichever is appropriate.)

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

 

 

Est.

 

 

 

Do you currently hold citizenship with this country?

 

 

 

 

 

 

YES

NO

 

Provide explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide country of citizenship.

During what period of time did you hold citizenship with this country?

 

 

 

 

 

(Provide the date range that you held this citizenship, beginning with the date it

 

 

 

 

 

was acquired through its termination or "Present," whichever is appropriate.)

 

How did you acquire this non-U.S. citizenship you now have or previously had?

From Date (Month/Year)

 

To Date (Month/Year)

Present

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

Do you currently hold citizenship with this country?

 

 

 

 

 

 

YES

NO

 

Provide explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?

YES

NO (If NO, proceed to Section 11)

 

 

 

 

 

 

Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.

Entry #1

Provide the country in which the passport (or identity card) was issued.

 

Provide the date the passport (or identity card) was issued. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

Provide the place the passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

Last name

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

Provide the passport (or identity card) number.

 

Provide the passport (or identity card) expiration date. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Have you EVER used this passport (or identity card) for foreign travel?

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

From date (Month/Year)

 

 

To date (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#5

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#6

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 8

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (CONTINUED)

Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.

Entry #2

Provide the country in which the passport (or identity card) was issued.

 

Provide the date the passport (or identity card) was issued. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the place the passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

Last name

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

Provide the passport (or identity card) number.

 

Provide the passport (or identity card) expiration date. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Have you EVER used this passport (or identity card) for foreign travel?

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

From date (Month/Year)

 

 

To date (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#5

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#6

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 9

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 11 - Where You Have Lived

Form approved: OMB No. 3206 0258

List the places where you have lived beginning with your present residence and working back 7 years. Residences for the entire period must be accounted for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you

were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th birthday unless to provide a minimum of 2 years residence history.

You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.

For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew you for periods of residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for residence.

Enter residence information.

Entry #1

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 10

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 11 - Where You Have Lived - (CONTINUED)

Form approved: OMB No. 3206 0258

Enter residence information.

Entry #2

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 11

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 11 - Where You Have Lived - (CONTINUED)

Enter residence information.

Entry #3

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 12

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 11 - Where You Have Lived - (CONTINUED)

Enter residence information.

Entry #4

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 13

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 12 - Where You Went to School

Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.

(a)Have you attended any schools in the last 7 years?

YES NO

(b)Have you received a degree or diploma more than 7 years ago? YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)

Entry #1

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For

assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For

assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know

Enter your Social Security Number before going to the next page

Page 14

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 12 - Where You Went to School - (CONTINUED)

Entry #2 (CONTINUED)

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #3

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise,

provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

First name

 

Last name

I don't know

 

 

 

 

 

 

 

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 15

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 12 - Where You Went to School - (CONTINUED)

Entry #4

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For

assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 16

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #1

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #1

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

Provide dates of employment.

 

 

 

 

 

Select the employment status for

 

Provide your assigned duty station during this period.

From Date

To Date

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

Provide the rank/position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

I don't know

Provide supervisor's telephone number. Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

City

 

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do/did your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 17

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #1

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number

 

Extension

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below).

 

Not

From date (Month/Year)

 

 

To date (Month/Year)

 

 

Position Title

Supervisor

 

 

Applicable

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is/was your physical work address different than your employer's address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

Provide telephone number

Extension

 

International or DSN phone number

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

APO or FPO

 

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

 

 

 

Provide the position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

 

I don't know

Provide supervisor's telephone number. Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

City

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did/does your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 18

Provide the telephone number for this address.
Telephone numberExtension

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #1

13A.3 Complete the following if employment type is self-employment

 

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

 

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is your physical work address different than your employment address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

International or DSN phone number

Day Night

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of someone that can verify your self-employment.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the telephone number for this person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your self-employment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 19

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #1

Entry #1

Entry #1

13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment.

 

 

 

Provide the name of someone that can verify your unemployment activities

From Date (Month/Year)

To Date(Month/Year)

 

 

and means of support.

 

 

Present

Last name

First name

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

Provide the telephone number for this person.

Verifier telephone number Extension

 

International or DSN phone number

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your unemployment verifier have an APO/FPO address?

YES

 

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

Provide the reason for leaving the employment activity.

For this employment have any of the following happened to you in the last seven (7) years?

Fired Quit after being told you would be fired Left by mutual agreement following charges or allegations of misconduct Left by mutual agreement

following notice of unsatisfactory performance.

YES

NO (If NO, proceed to 13A.6)

 

 

 

 

 

 

 

 

 

 

 

Select your type of incident:

Reason:

 

 

Employment departure date

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for being fired.

 

Provide the date you were fired. (Month/Year)

 

 

 

 

Fired

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for quitting.

 

Provide the date you quit after being told you would be

 

 

 

 

Quit after being told you would be

 

 

 

fired. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

fired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations

 

 

 

 

Left by mutual agreement following

 

 

 

of misconduct. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

charges or allegations of misconduct

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for unsatisfactory performance.

Provide the date you left by mutual agreement following

 

 

 

 

Left by mutual agreement following

 

 

 

a notice of unsatisfactory performance. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice of unsatisfactory performance

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

 

 

YES

NO

 

 

 

 

 

 

 

#1

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#2

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 20

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #2

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #2

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

 

Provide dates of employment.

 

 

 

 

 

Select the employment status for

 

 

Provide your assigned duty station during this period.

 

 

 

 

 

 

 

 

 

From Date

To Date

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

Provide the rank/position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

I don't know

Provide supervisor's telephone number. Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

City

 

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do/did your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 21

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #2

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number

 

Extension

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below).

Not

From date (Month/Year)

 

 

To date (Month/Year)

 

 

Position Title

Supervisor

Applicable

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is/was your physical work address different than your employer's address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

Provide telephone number

Extension

 

International or DSN phone number

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

APO or FPO

 

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

 

 

 

Provide the position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

 

I don't know

Provide supervisor's telephone number. Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

City

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did/does your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 22

Provide the telephone number for this address.
Telephone numberExtension

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #2

13A.3 Complete the following if employment type is self-employment

 

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

 

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is your physical work address different than your employment address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

International or DSN phone number

Day Night

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of someone that can verify your self-employment.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the telephone number for this person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your self-employment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 23

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #2

Entry #2

Entry #2

13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment.

 

 

 

Provide the name of someone that can verify your unemployment activities

From Date (Month/Year)

To Date(Month/Year)

 

 

and means of support.

 

 

Present

Last name

First name

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

Provide the telephone number for this person.

Verifier telephone number Extension

 

International or DSN phone number

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your unemployment verifier have an APO/FPO address?

YES

 

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

Provide the reason for leaving the employment activity.

For this employment have any of the following happened to you in the last seven (7) years?

Fired Quit after being told you would be fired Left by mutual agreement following charges or allegations of misconduct Left by mutual agreement

following notice of unsatisfactory performance.

YES

NO (If NO, proceed to 13A.6)

 

 

 

 

 

 

 

 

 

Select your type of incident:

Reason:

 

 

Employment departure date

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for being fired.

 

Provide the date you were fired. (Month/Year)

 

 

 

Fired

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for quitting.

 

Provide the date you quit after being told you would be

 

 

 

Quit after being told you would be

 

 

 

fired. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

fired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations

 

 

 

Left by mutual agreement following

 

 

 

of misconduct. (Month/Year)

 

 

 

 

 

 

 

 

 

charges or allegations of misconduct

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for unsatisfactory performance.

Provide the date you left by mutual agreement following

 

 

 

Left by mutual agreement following

 

 

 

a notice of unsatisfactory performance. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice of unsatisfactory performance

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

 

 

YES

NO

 

 

 

 

 

 

 

#1

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#2

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 24

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #3

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #3

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

 

Provide dates of employment.

 

 

 

 

 

Select the employment status for

 

 

Provide your assigned duty station during this period.

 

 

 

 

 

 

 

 

 

From Date

To Date

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

Provide the rank/position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

I don't know

Provide supervisor's telephone number. Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

City

 

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do/did your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 25

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #3

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number

 

Extension

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below).

Not

From date (Month/Year)

 

 

To date (Month/Year)

 

 

Position Title

Supervisor

Applicable

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is/was your physical work address different than your employer's address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

Provide telephone number

Extension

 

International or DSN phone number

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

APO or FPO

 

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

 

 

 

Provide the position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

 

I don't know

Provide supervisor's telephone number. Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

City

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did/does your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 26

Provide the telephone number for this address.
Telephone numberExtension

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #3

13A.3 Complete the following if employment type is self-employment

 

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

 

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is your physical work address different than your employment address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

International or DSN phone number

Day Night

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of someone that can verify your self-employment.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the telephone number for this person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your self-employment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 27

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #3

Entry #3

Entry #3

13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment.

 

 

 

Provide the name of someone that can verify your unemployment activities

From Date (Month/Year)

To Date(Month/Year)

 

 

and means of support.

 

 

Present

Last name

First name

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

Provide the telephone number for this person.

Verifier telephone number Extension

 

International or DSN phone number

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your unemployment verifier have an APO/FPO address?

YES

 

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

Provide the reason for leaving the employment activity.

For this employment have any of the following happened to you in the last seven (7) years?

Fired Quit after being told you would be fired Left by mutual agreement following charges or allegations of misconduct Left by mutual agreement

following notice of unsatisfactory performance.

YES

NO (If NO, proceed to 13A.6)

 

 

 

 

 

 

 

 

 

Select your type of incident:

Reason:

 

 

Employment departure date

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for being fired.

 

Provide the date you were fired. (Month/Year)

 

 

 

Fired

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for quitting.

 

Provide the date you quit after being told you would be

 

 

 

Quit after being told you would be

 

 

 

fired. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

fired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations

 

 

 

Left by mutual agreement following

 

 

 

of misconduct. (Month/Year)

 

 

 

 

 

 

 

 

 

charges or allegations of misconduct

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for unsatisfactory performance.

Provide the date you left by mutual agreement following

 

 

 

Left by mutual agreement following

 

 

 

a notice of unsatisfactory performance. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice of unsatisfactory performance

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

 

 

YES

NO

 

 

 

 

 

 

 

#1

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 28

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #4

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #4

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

 

Provide dates of employment.

 

 

 

 

Select the employment status for

 

Provide your assigned duty station during this period.

 

From Date

To Date

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

Provide the rank/position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

I don't know

Provide supervisor's telephone number. Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

City

 

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do/did your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 29

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #4

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number

 

Extension

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below).

Not

From date (Month/Year)

 

 

To date (Month/Year)

 

 

Position Title

Supervisor

Applicable

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is/was your physical work address different than your employer's address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

Provide telephone number

Extension

 

International or DSN phone number

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

APO or FPO

 

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

 

 

 

Provide the position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

 

I don't know

Provide supervisor's telephone number. Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

City

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did/does your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 30

Provide the telephone number for this address.
Telephone numberExtension

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #4

13A.3 Complete the following if employment type is self-employment

 

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

 

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is your physical work address different than your employment address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

International or DSN phone number

Day Night

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of someone that can verify your self-employment.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the telephone number for this person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your self-employment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 31

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #4

Entry #4

Entry #4

13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment.

 

 

 

Provide the name of someone that can verify your unemployment activities

From Date (Month/Year)

To Date(Month/Year)

 

 

and means of support.

 

 

Present

Last name

First name

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

Provide the telephone number for this person.

Verifier telephone number Extension

 

International or DSN phone number

 

 

Day

 

Night

 

 

 

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your unemployment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

Provide the reason for leaving the employment activity.

For this employment have any of the following happened to you in the last seven (7) years?

Fired Quit after being told you would be fired Left by mutual agreement following charges or allegations of misconduct Left by mutual agreement

following notice of unsatisfactory performance.

YES

NO (If NO, proceed to 13A.6)

 

 

 

 

 

 

 

 

 

 

 

Select your type of incident:

Reason:

 

 

Employment departure date

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for being fired.

 

Provide the date you were fired. (Month/Year)

 

 

 

 

Fired

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for quitting.

 

Provide the date you quit after being told you would be

 

 

 

 

Quit after being told you would be

 

 

 

fired. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

fired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations

 

 

 

 

Left by mutual agreement following

 

 

 

of misconduct. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

charges or allegations of misconduct

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for unsatisfactory performance.

Provide the date you left by mutual agreement following

 

 

 

 

Left by mutual agreement following

 

 

 

a notice of unsatisfactory performance. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice of unsatisfactory performance

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

 

 

YES

NO

 

 

 

 

 

 

 

#1

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 32

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13B - Employment Activities - Former Federal Service

Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?

YES

NO (If NO, proceed to Section 13C)

Complete the following if you selected "Yes" to having former federal civilian employment, excluding military service, NOT indicated previously.

Entry #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide dates of federal civilian employment.

 

 

 

 

Provide the name of the federal agency for

 

 

 

From Date (Month/Year)

 

 

To Date (Month/Year)

 

 

Present

which you are/were employed.

Provide your position title.

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide dates of federal civilian employment.

 

 

 

 

Provide the name of the federal agency for

 

 

 

From Date (Month/Year)

 

 

To Date (Month/Year)

 

 

Present

 

which you are/were employed.

Provide your position title.

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide dates of federal civilian employment.

 

 

 

 

Provide the name of the federal agency for

 

 

 

From Date (Month/Year)

 

Est.

To Date (Month/Year)

 

 

Present

 

which you are/were employed.

Provide your position title.

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide dates of federal civilian employment.

 

 

 

 

Provide the name of the federal agency for

 

 

 

From Date (Month/Year)

 

Est.

To Date (Month/Year)

 

 

Present

 

which you are/were employed.

Provide your position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

Section 13C - Employment Record

Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed?

-Fired from a job?

-Quit a job after being told you would be fired?

-Have you left a job by mutual agreement following charges or allegations of misconduct?

-Left a job by mutual agreement following notice of unsatisfactory performance?

-Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as violation of a security policy?

YES (If YES, you will be required to add an additional employment in Section 13A)

NO (If NO, proceed to Section 14)

Section 14 - Selective Service Record

Were you born a male after December 31, 1959?

YES

NO (If NO, proceed to Section 15)

 

 

 

Have you registered with the Selective Service System (SSS)?

The Selective Service website, www.sss.gov, can help provide the

Yes

 

 

Provide registration number:

registration number for persons who have registered. Note: Selective

 

 

Service Number is not your Social Security Number.

 

 

 

 

No

 

 

Provide explanation:

 

 

 

 

I don't know

 

Provide explanation:

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 33

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 15 - Military History

Have you EVER served in the U.S. Military?

Form approved: OMB No. 3206 0258

YES

NO (If NO, proceed to 15.2)

15.1(a) Complete the following if you responded 'Yes' to having served in the U.S. Military.

Entry #1

Provide the branch of service you served in.

Army

Air National

 

Guard

Army National

State of service, if National Guard

Officer or enlisted

Not Applicable

Officer

Provide your service number.

Guard

Marine Corps

Provide your status

Active Duty

Enlisted

Provide your dates of service.

Navy

Coast Guard

Air Force

Active Reserve Inactive Reserve

From Date

To Date

 

Present

 

(Month/Year)

(Month/Year)

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?

YES NO

Provide the type of discharge you received:

Honorable

Under Other than

Bad Conduct

 

Honorable Conditions

 

Dishonorable

General

Other (provide type)

Provide the date of discharge listed

(Month/Year)

Est.

Provide the reason(s) for the discharge, if discharge is other than Honorable

Entry #2

Provide the branch of service you served in.

Army

Air National

 

Guard

Army National

State of service, if National Guard

Officer or enlisted

Not Applicable

Officer

Provide your service number.

Guard

Marine Corps

Provide your status

Active Duty

Enlisted

Provide your dates of service.

Navy

Coast Guard

Air Force

Active Reserve Inactive Reserve

From Date

To Date

 

Present

 

(Month/Year)

(Month/Year)

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?

YES NO

Provide the type of discharge you received:

Honorable

Under Other than

Bad Conduct

 

Honorable Conditions

 

Dishonorable

General

Other (provide type)

Provide the date of discharge listed

(Month/Year)

Est.

Provide the reason(s) for the discharge, if discharge is other than Honorable

Enter your Social Security Number before going to the next page

Page 34

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 15 - Military History - (CONTINUED)

15.1(b)

In the last seven (7) years, have you been subject to court martial or other disciplinary procedure

YES

NO (If NO proceed to 15.2)

 

under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135

 

 

 

Court of Inquiry, etc?

Complete the following if you responded 'Yes' to In the last seven (7) years, have you been subject to court martial or other disciplinary procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.

Entry #1

Provide the date of the court martial or other disciplinary procedure. (Month/Year)

 

 

 

Est.

 

 

Provide a description of the Uniform Code of Military Justice (UCMJ)

Provide the name of the disciplinary procedure, such as Court Martial,

offense(s) for which you were charged.

Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.

 

 

Provide the description of the military court or other authority in which you

Provide the description of the final outcome of the disciplinary procedure,

were charged (title of court or convening authority, address, to include city

such as found guilty, found not guilty, fine, reduction in rank,

and state or country if overseas).

imprisonment, etc.

 

 

 

 

Entry #2

Provide the date of the court martial or other disciplinary procedure. (Month/Year)

 

 

 

Est.

 

 

Provide a description of the Uniform Code of Military Justice (UCMJ)

Provide the name of the disciplinary procedure, such as Court Martial,

offense(s) for which you were charged.

Article 15, Captain's Mast, Article 135 Court of Inquiry, etc.

 

 

Provide the description of the military court or other authority in which you

Provide the description of the final outcome of the disciplinary procedure,

were charged (title of court or convening authority, address, to include city

such as found guilty, found not guilty, fine, reduction in rank,

and state or country if overseas).

imprisonment, etc.

 

 

 

 

Enter your Social Security Number before going to the next page

Page 35

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 15 - Military History - (CONTINUED)

15.2

Have you EVER served, as a civilian or military member in a foreign country's military, intelligence,

YES

NO (If NO, proceed to Section 16)

 

 

diplomatic, security forces, militia, other defense force, or government agency?

Complete the following if you responded 'Yes' to having EVER served as a civilian or military member in a foreign country's military, intelligence, diplomatic, security forces, militia, other defense force, or government agency.

Entry #1

During your foreign service, which organization were you serving under?

 

Military (Army, Navy, Air Force, Marines, etc.),

Specify

 

 

 

 

 

Intelligence Service

 

Security Forces

 

 

 

 

 

Diplomatic Service

 

Militia

 

 

 

 

 

Other Government Agency, Specify

 

 

 

 

 

 

 

Other Defense Forces, Specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of the foreign organization.

 

Provide your period of service.

 

Present

 

 

 

 

From Date (Month/Year)

To Date (Month/Year)

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

Provide the name of the country.

Provide your highest position/rank held.

Provide division/department/office in which you served.

Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.

Entry #2

During your foreign service, which organization were you serving under?

 

 

 

 

Military (Army, Navy, Air Force, Marines, etc.),

Specify

 

 

 

 

Intelligence Service

 

Security Forces

 

 

 

 

Diplomatic Service

 

Militia

 

 

 

 

Other Government Agency, Specify

 

 

 

 

 

 

Other Defense Forces, Specify

 

 

 

 

 

 

 

 

 

 

 

Provide the name of the foreign organization.

 

Provide your period of service.

 

Present

 

 

 

From Date (Month/Year)

To Date (Month/Year)

 

 

 

Est.

 

 

Est.

 

 

 

 

Provide the name of the country.

Provide your highest position/rank held.

Provide division/department/office in which you served.

Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.

Enter your Social Security Number before going to the next page

Page 36

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 16 - People Who Know You Well

Form approved: OMB No. 3206 0258

Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association with you covers at least the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.

Entry #1

Provide dates known.

 

 

Provide relationship to you. (Select all that apply)

 

From Date (Month/Year)

To Date (Month/Year)

Present

Neighbor

Work associate

Other (Provide explanation)

 

Est.

 

Est.

Friend

Schoolmate

 

 

 

 

 

 

 

 

 

Provide full name.

 

 

 

 

 

 

Last name

 

First name

 

 

Middle name

Suffix

Provide e-mail address for this person.

I don't know

Provide rank/title

Not applicable

Provide telephone number for this person.

I don't know

International or DSN

Extension

phone number

 

 

 

Day

Night

Provide mobile/cell telephone number for this person.

I don't know

International or DSN

Extension

phone number

 

 

 

Day

Night

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

Street

 

City

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide dates known.

 

 

 

Provide relationship to you. (Select all that apply)

 

 

From Date (Month/Year)

To Date (Month/Year)

Present

Neighbor

Work associate

Other (Provide explanation)

 

 

Est.

 

 

Est.

Friend

Schoolmate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide full name.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

Provide e-mail address for this person.

I don't know

Provide rank/title

Not applicable

Provide telephone number for this person.

I don't know

International or DSN

Extension

phone number

 

 

 

Day

Night

Provide mobile/cell telephone number for this person.

I don't know

International or DSN

Extension

phone number

 

 

 

Day

Night

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

Street

 

City

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide dates known.

 

 

 

Provide relationship to you. (Select all that apply)

 

 

From Date (Month/Year)

To Date (Month/Year)

Present

Neighbor

Work associate

Other (Provide explanation)

 

 

Est.

 

 

Est.

Friend

Schoolmate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide full name.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

Provide e-mail address for this person.

I don't know

Provide rank/title

Not applicable

Provide telephone number for this person.

I don't know

International or DSN

Extension

phone number

 

 

 

Day

Night

Provide mobile/cell telephone number for this person.

I don't know

International or DSN

Extension

phone number

 

 

 

Day

Night

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Enter your Social Security Number before going to the next page

Page 37

U.S. Passport (current or most recent)

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 17 - Marital/Relationship Status

Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic partnership:

Never entered in a civil marriage, legally recognized civil union, or legally

Separated (Complete 17.1 and 17.3)

recognized domestic partnership (Complete 17.3)

Annulled (Complete 17.2 and 17.3)

 

Currently in a civil marriage, legally recognized civil union, or legally

Divorced/Dissolved (Complete 17.2 and 17.3)

recognized domestic partnership (Complete 17.1 and 17.3)

Widowed (Complete 17.2 and 17.3)

 

17.1Complete the following if you selected currently in a civil marriage, legally recognized civil union, or legally recognized domestic partnership or Separated. Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally recognized domestic partnership, or the person from whom you are currently separated.

Provide full name.

 

 

 

Provide the date of birth.

Last name

First name

Middle name

Suffix

(Month/Day/Year)

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide place of birth.

 

 

 

 

 

 

City

County

State

Country (required)

If the person is foreign born, provide one type of documentation that he or she possesses and the document number.

None (Provide explanation)

FS 240 or 545

 

 

 

DS 1350

 

 

Alien Registration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Certificate of

 

 

U.S. Certificate of Naturalization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide document number.

 

 

 

 

 

 

Provide U.S. Social Security Number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide other names used (such as maiden name, names by other marriages, civil marriages, legally recognized

 

 

 

 

civil unions, or legally recognized domestic partnerships, nicknames, etc., and provide dates used for each name).

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

 

 

 

First name

 

 

 

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

 

 

 

First name

 

 

 

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

 

 

 

First name

 

 

 

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

 

 

 

First name

 

 

 

 

 

 

Middle name

 

 

Suffix

 

Maiden name?

From (Month/Year)

 

Est.

To (Month/Year)

 

Present

 

 

 

 

 

Est.

 

 

Provide country(ies) of citizenship.

 

Country #1

Country #2

Provide date when you entered into your civil

marriage, civil union, or domestic partnership. (Month/Day/Year)

Est.

Enter your Social Security Number before going to the next page

Page 38

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 17 - Marital/Relationship Status - (CONTINUED)

17.1Complete the following if you selected currently in a civil marriage, legally recognized civil union, or legally recognized domestic partnership or Separated. Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally recognized domestic partnership, or the person from whom you are currently separated. (Continued)

Provide location. (Provide City and Country if outside the United States; otherwise, provide City or County and State.)

City

 

 

 

 

County

 

 

State

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

 

Use my current address

 

 

Street

 

 

 

 

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number. Extension

 

Day

 

Use my current telephone number

Provide email address.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the person have an APO/FPO address within the United States?

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

APO or FPO

 

APO/FPO State Code

 

Zip Code

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/ fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

Are you separated?

YES

 

 

Provide date of separation.

 

 

(Month/Day/Year)

 

 

 

NO

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If legally separated, provide the location of the record.

 

 

Not Applicable

(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

 

 

City

State

Zip Code

Country

 

 

Enter your Social Security Number before going to the next page

Page 39

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 17 - Marital/Relationship Status - (CONTINUED)

Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?

YES

NO

17.2Complete the following if you selected divorced/dissolved, annulled, or widowed. Provide information about any person from whom you are divorced/ dissolved, annulled, or widowed.

Entry #1

Provide the full name.

 

 

 

 

 

 

Provide the date of birth.

 

Last name

First name

 

Middle name

 

Suffix

(Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide the place of birth.

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip Code

Country (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the country(ies) of citizenship.

 

 

 

 

 

 

 

 

 

 

Country #1

 

Country #2

 

 

 

 

 

 

Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)

Est.

Provide the location. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)

City

State

Country

Provide the status.

Divorced/Dissolved Widowed Annulled

Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)

Est.

Provide where the record of divorce/dissolution or annulment is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

Is this person deceased?

 

 

 

 

 

 

YES

NO (If NO, complete (A))

I don't know

 

 

 

 

 

 

 

(a) Provide last known address of the person from whom you are divorced/dissolved or annulled. (Provide City and Country if outside the

 

I don't know

 

United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Enter your Social Security Number before going to the next page

Page 40

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 17 - Marital/Relationship Status - (CONTINUED)

Do you have a person from whom you are divorced/dissolved, annulled, or widowed to report?

YES

NO

17.2Complete the following if you selected "divorced/dissolved", "annulled", or "widowed". Provide information about any person from whom you are divorced/dissolved, annulled, or widowed.

Entry #2

Provide the full name.

 

 

 

 

 

 

 

Provide the date of birth.

 

Last name

First name

 

 

Middle name

 

Suffix

(Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the place of birth.

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip Code

Country (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the country(ies) of citizenship.

 

 

 

 

 

 

 

 

 

 

 

Country #1

 

 

Country #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the date your civil marriage, civil union, or domestic partnership was legally recognized. (Month/Day/Year)

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the location. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)

 

 

 

 

City

 

State

 

Country

 

 

 

 

 

 

Provide the status.

Divorced/Dissolved Widowed Annulled

Provide the date divorced/dissolved, annulled or widowed. (Month/Day/Year)

Est.

Provide where the record of divorce/dissolution or annulment is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

Is this person deceased?

 

 

 

 

 

 

YES

NO (If NO, complete (A))

I don't know

 

 

 

 

 

 

 

(a) Provide last known address of the person from whom you are divorced/dissolved or annulled. (Provide City and Country if outside the

 

I don't know

 

United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Enter your Social Security Number before going to the next page

Page 41

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 17 - Marital/Relationship Status - (CONTINUED)

17.3 Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic

YES

NO (If NO, proceed to Section 18)

partner, with whom you share bonds of affection, obligation, or other commitment, as opposed to a

 

 

person with whom you live for reasons of convenience (e.g. a roommate)? If so, complete the following.

 

 

If the person was born outside the U.S., provide citizenship information.

 

 

Complete the following if you presently reside with a cohabitant.

Entry #1

Provide the cohabitant full name.

 

 

 

 

Provide the cohabitant date of birth.

Last name

First name

Middle name

 

Suffix

Date (Month/Day/Year)

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the cohabitant place of birth.

 

 

 

 

 

 

 

City

 

State

Country (Required)

 

 

 

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.

FS 240 or 545

DS 1350

U.S. Certificate of Citizenship

U.S. Passport (current or most recent)

Alien Registration

U.S. Certificate of Naturalization

None (Provide explanation)

Other (Provide explanation)

 

Provide document number.

 

 

 

Provide your cohabitant's U.S. Social Security Number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each

 

Not applicable

 

 

 

name was used).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your cohabitant's country(ies) of citizenship.

 

 

 

 

 

Provide date cohabitation began.

Country #1

 

 

 

Country #2

 

 

 

 

(Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 42

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 17 - Marital/Relationship Status - (CONTINUED)

17.3 Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic

YES

NO (If NO, proceed to Section 18)

partner, with whom you share bonds of affection, obligation, or other commitment, as opposed to a

 

 

person with whom you live for reasons of convenience (e.g. a roommate)? If so, complete the following.

 

 

If the person was born outside the U.S., provide citizenship information.

 

 

Complete the following if you presently reside with a cohabitant.

Entry #2

Provide the cohabitant full name.

 

 

 

 

Provide the cohabitant date of birth.

Last name

First name

Middle name

 

Suffix

Date (Month/Day/Year)

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the cohabitant place of birth.

 

 

 

 

 

 

 

City

 

State

Country (Required)

 

 

 

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.

FS 240 or 545

DS 1350

U.S. Certificate of Citizenship

U.S. Passport (current or most recent)

Alien Registration

U.S. Certificate of Naturalization

None (Provide explanation)

Other (Provide explanation)

 

Provide document number.

 

 

 

Provide your cohabitant's U.S. Social Security Number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each

 

Not applicable

 

 

 

name was used).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

 

First name

 

 

 

Middle name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

To (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your cohabitant's country(ies) of citizenship.

 

 

 

 

 

Provide date cohabitation began.

Country #1

 

 

 

Country #2

 

 

 

 

(Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 43

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 18 - RelativES

Form approved: OMB No. 3206 0258

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Select all that apply.

Mother

Father

Stepmother

Stepfather

Foster parent

Child (including adopted/foster)

Stepchild

Brother

Sister

Stepbrother

Stepsister

Half-brother

Half-sister

Father-in-law

Mother-in-law

Guardian

Entry #1

Provide relative type.

Provide your relative's full name.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

Provide your relative's date of birth.

Provide your relative's place of birth.

 

 

 

Date (Month/Year)

City

State

Country (Required)

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relative's country(ies) of citizenship.

 

 

 

Country #1

 

Country #2

 

 

 

Entry #1

18.1Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,

Sister, Stepbrother, Stepsister, Half-brother, Half-sister.

If mother, provide your mother's maiden name.

 

Same as listed

I don't know

 

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

Has this relative used any other names?

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former

Not applicable

 

name, alias, or nickname).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 44

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 18 - Relatives - (CONTINUED)

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #1

18.2Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Does this relative have an APO/FPO address?

 

 

 

Provide your relative's APO/FPO address.

 

 

 

YES

 

 

 

 

 

 

 

NO

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 45

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 18 - RelativES - (CONTINUED)

Form approved: OMB No. 3206 0258

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Select all that apply.

Mother

Father

Stepmother

Stepfather

Foster parent

Child (including adopted/foster)

Stepchild

Brother

Sister

Stepbrother

Stepsister

Half-brother

Half-sister

Father-in-law

Mother-in-law

Guardian

Entry #2

Provide relative type.

Provide your relative's full name.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

Provide your relative's date of birth.

Provide your relative's place of birth.

 

 

 

Date (Month/Year)

City

State

Country (Required)

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relative's country(ies) of citizenship.

 

 

 

Country #1

 

Country #2

 

 

 

Entry #2

18.1Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,

Sister, Stepbrother, Stepsister, Half-brother, Half-sister.

If mother, provide your mother's maiden name.

 

Same as listed

I don't know

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

Has this relative used any other names?

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former

Not applicable

name, alias, or nickname).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 46

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 18 - Relatives - (CONTINUED)

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #2

18.2Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Does this relative have an APO/FPO address?

 

 

 

Provide your relative's APO/FPO address.

 

 

 

YES

 

 

 

 

 

 

 

NO

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 47

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 18 - RelativES - (CONTINUED)

Form approved: OMB No. 3206 0258

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Select all that apply.

Mother

Father

Stepmother

Stepfather

Foster parent

Child (including adopted/foster)

Stepchild

Brother

Sister

Stepbrother

Stepsister

Half-brother

Half-sister

Father-in-law

Mother-in-law

Guardian

Entry #3

Provide relative type.

Provide your relative's full name.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

Provide your relative's date of birth.

Provide your relative's place of birth.

 

 

 

Date (Month/Year)

City

State

Country (Required)

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relative's country(ies) of citizenship.

 

 

 

Country #1

 

Country #2

 

 

 

Entry #3

18.1Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,

Sister, Stepbrother, Stepsister, Half-brother, Half-sister.

If mother, provide your mother's maiden name.

 

Same as listed

I don't know

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

Has this relative used any other names?

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former

Not applicable

name, alias, or nickname).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 48

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 18 - Relatives - (CONTINUED)

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #3

18.2Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Does this relative have an APO/FPO address?

 

 

 

Provide your relative's APO/FPO address.

 

 

 

YES

 

 

 

 

 

 

 

NO

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 49

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 18 - RelativES - (CONTINUED)

Form approved: OMB No. 3206 0258

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Select all that apply.

Mother

Father

Stepmother

Stepfather

Foster parent

Child (including adopted/foster)

Stepchild

Brother

Sister

Stepbrother

Stepsister

Half-brother

Half-sister

Father-in-law

Mother-in-law

Guardian

Entry #4

Provide relative type.

Provide your relative's full name.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

Provide your relative's date of birth.

Provide your relative's place of birth.

 

 

 

Date (Month/Year)

City

State

Country (Required)

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relative's country(ies) of citizenship.

 

 

 

Country #1

 

Country #2

 

 

 

Entry #4

18.1Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,

Sister, Stepbrother, Stepsister, Half-brother, Half-sister.

If mother, provide your mother's maiden name.

 

Same as listed

I don't know

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

Has this relative used any other names?

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former

Not applicable

name, alias, or nickname).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 50

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 18 - Relatives - (CONTINUED)

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #4

18.2Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Does this relative have an APO/FPO address?

 

 

 

Provide your relative's APO/FPO address.

 

 

 

YES

 

 

 

 

 

 

 

NO

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 51

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 18 - RelativES - (CONTINUED)

Form approved: OMB No. 3206 0258

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Select all that apply.

Mother

Father

Stepmother

Stepfather

Foster parent

Child (including adopted/foster)

Stepchild

Brother

Sister

Stepbrother

Stepsister

Half-brother

Half-sister

Father-in-law

Mother-in-law

Guardian

Entry #5

Provide relative type.

Provide your relative's full name.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

Provide your relative's date of birth.

Provide your relative's place of birth.

 

 

 

Date (Month/Year)

City

State

Country (Required)

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relative's country(ies) of citizenship.

 

 

 

Country #1

 

Country #2

 

 

 

Entry #5

18.1Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,

Sister, Stepbrother, Stepsister, Half-brother, Half-sister.

If mother, provide your mother's maiden name.

 

Same as listed

I don't know

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

Has this relative used any other names?

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former

Not applicable

name, alias, or nickname).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 52

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 18 - Relatives - (CONTINUED)

Entry #5

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

 

18.2Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Does this relative have an APO/FPO address?

 

 

 

Provide your relative's APO/FPO address.

 

 

 

YES

 

 

 

 

 

 

 

NO

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 53

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 18 - RelativES - (CONTINUED)

Form approved: OMB No. 3206 0258

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Select all that apply.

Mother

Father

Stepmother

Stepfather

Foster parent

Child (including adopted/foster)

Stepchild

Brother

Sister

Stepbrother

Stepsister

Half-brother

Half-sister

Father-in-law

Mother-in-law

Guardian

Entry #6

Provide relative type.

Provide your relative's full name.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

Provide your relative's date of birth.

Provide your relative's place of birth.

 

 

 

Date (Month/Year)

City

State

Country (Required)

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relative's country(ies) of citizenship.

 

 

 

Country #1

 

Country #2

 

 

 

Entry #6

18.1Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother,

Sister, Stepbrother, Stepsister, Half-brother, Half-sister.

 

If mother, provide your mother's maiden name.

 

Same as listed

I don't know

 

 

 

 

Last name

 

 

First name

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has this relative used any other names?

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

Provide other names used and the period of time that your relative used them (such as maiden, name by a former marriage, former

Not applicable

 

name, alias, or nickname).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

Last name

 

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden name?

From (Month/Year)

 

To (Month/Year)

Present

Provide the reason(s) why the name changed.

 

 

 

YES

NO

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 54

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 18 - Relatives - (CONTINUED)

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Entry #6

18.2Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Does this relative have an APO/FPO address?

 

 

 

Provide your relative's APO/FPO address.

 

 

 

YES

 

 

 

 

 

 

 

NO

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 55

If yes, provide explanation.
If yes, provide explanation.

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 19 - Foreign Countries You have Visited

Have you traveled outside the U.S. in the last seven (7) years?

YES

NO (If NO, proceed to Section 20)

 

 

 

 

 

Has your travel in the last seven (7) years been solely for U.S. Government business/military overseas

YES (If YES, proceed to Section 20)

NO

assignment on official government orders (i.e., no personal trips in conjunction with the official U.S.

 

 

 

Government business)?

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business on official government orders.

Entry #1

Provide the country visited.

Provide the dates of your travel to this country.

 

 

Provide the total number of days involved in the visit.

 

 

From (Month/Year)

 

 

To (Month/Year)

 

Present

1-5

11-20

More than 30

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

6-10

21-30

Many short trips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the purpose of the travel to this country (Select all that apply).

 

 

Business/Professional

 

Education

 

Trade shows, conferences, and seminars

 

Other

 

 

Volunteer activities

 

 

Tourism

 

Visit family or friends

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when entering or leaving this country?

YES NO

While traveling to or in this country, were you involved in any encounter with the police?

YES

 

If yes, provide explanation.

 

NO

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organizations?

YES

 

If yes, provide explanation.

 

NO

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business on official government orders.

Entry #2

Provide the country visited.

Provide the dates of your travel to this country.

 

 

Provide the total number of days involved in the visit.

 

 

From (Month/Year)

 

 

To (Month/Year)

 

Present

1-5

11-20

More than 30

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

6-10

21-30

Many short trips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the purpose of the travel to this country (Select all that apply).

 

 

Business/Professional

 

Education

 

Trade shows, conferences, and seminars

 

Other

 

 

Volunteer activities

 

 

Tourism

 

Visit family or friends

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when entering or leaving this country?

YES NO

While traveling to or in this country, were you involved in any encounter with the police?

YES

 

If yes, provide explanation.

 

NO

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organizations?

YES

 

If yes, provide explanation.

 

NO

Enter your Social Security Number before going to the next page

Page 56

If yes, provide explanation.
If yes, provide explanation.

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 19 - Foreign Countries You have Visited - CONTINUED

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business on official government orders.

Entry #3

Provide the country visited.

Provide the dates of your travel to this country.

 

 

Provide the total number of days involved in the visit.

 

 

From (Month/Year)

 

 

To (Month/Year)

 

Present

1-5

11-20

More than 30

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

6-10

21-30

Many short trips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the purpose of the travel to this country (Select all that apply).

 

 

Business/Professional

 

Education

 

Trade shows, conferences, and seminars

 

Other

 

 

Volunteer activities

 

 

Tourism

 

Visit family or friends

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when entering or leaving this country?

YES NO

While traveling to or in this country, were you involved in any encounter with the police?

YES

 

If yes, provide explanation.

 

NO

While traveling to or in this country, were you involved in any encounter with the police?

YES

 

If yes, provide explanation.

 

NO

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business on official government orders.

Entry #4

Provide the country visited.

Provide the dates of your travel to this country.

 

 

Provide the total number of days involved in the visit.

 

 

From (Month/Year)

 

 

To (Month/Year)

 

Present

1-5

11-20

More than 30

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

6-10

21-30

Many short trips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the purpose of the travel to this country (Select all that apply).

 

 

Business/Professional

 

Education

 

Trade shows, conferences, and seminars

 

Other

 

 

Volunteer activities

 

 

Tourism

 

Visit family or friends

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when entering or leaving this country?

YES NO

While traveling to or in this country, were you involved in any encounter with the police?

YES

 

If yes, provide explanation.

 

NO

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organizations?

YES

 

If yes, provide explanation.

 

NO

Enter your Social Security Number before going to the next page

Page 57

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 20 - Police Record

Form approved: OMB No. 3206 0258

For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or the charge was dismissed. You need not report 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. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.

20.1

Have any of the following happened? (If 'Yes' you will be asked to provide details for each offense that

YES

NO (If NO, proceed to 20.2)

 

pertains to the actions that are identified below.)

 

 

 

-In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)

-In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

-In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).

-In the last seven (7) years have you been or are you currently on probation or parole?

-Are you currently on trial or awaiting a trial on criminal charges?

Entry #1

Entry #1

Provide the date of offense. (Month/Year)

Provide a description of the specific nature of the offense.

Est.

(a)Did this offense involve any of the following?

YES NO

(Select all that apply.)

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom you share a child in common?

Involve firearms or explosives?

Involve alcohol or drugs?

Provide the location where the offense occurred.

(Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

(b)Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other type of law enforcement official?

YES

NO (If NO, proceed to (c))

Provide the name of the law enforcement agency that arrested/cited/summoned you.

Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

(c)As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?

YES

 

Provide the name of the court.

 

(If YES, complete (c.1))

 

 

NO

 

Provide explanation

 

(c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser offense.

Felony/misdemeanor

Charge

Outcome

Date (Month/Year)

Est.

Est.

Est.

Est.

Enter your Social Security Number before going to the next page

Page 58

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 20 - Police Record - (CONTINUED)

Entry #1

Entry #1

(d)Were you sentenced as a result of this offense?

YES (If YES, complete (d.1))

NO (If NO, complete (d.2))

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(d.1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a description of the sentence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you sentenced to imprisonment for a term exceeding 1 year?

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

Were you incarcerated as a result of that sentence for not less than 1 year?

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

If the conviction resulted in imprisonment, provide the dates that you

 

Not Applicable

From Date

(Month/Year)

To Date (Month/Year)

 

Present

 

 

 

 

actually were incarcerated.

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If conviction resulted in probation or parole, provide the dates of

 

Not Applicable

From Date

(Month/Year)

To Date (Month/Year)

 

Present

 

 

 

 

probation or parole.

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(d.2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide explanation.

Enter your Social Security Number before going to the next page

Page 59

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 20 - Police Record - (CONTINUED)

Complete the following if you have responded 'Yes' to one of the following;

-In the last seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs)

-In the last seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

-In the last seven (7) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).

-In the last seven (7) years have you been or are you currently on probation or parole?

-Are you currently on trial or awaiting a trial on criminal charges?

Entry #2

Entry #2

Provide the date of offense. (Month/Year)

Provide a description of the specific nature of the offense.

Est.

(a)Did this offense involve any of the following?

YES NO

(Select all that apply.)

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom you share a child in common?

Involve firearms or explosives?

Involve alcohol or drugs?

Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

(b)Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other type of law enforcement official?

YES

NO (If NO, proceed to (c))

Provide the name of the law enforcement agency that arrested/cited/summoned you.

Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

(c)As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?

YES

 

Provide the name of the court.

 

(If YES, complete (c.1))

 

 

NO

 

Provide explanation

 

(c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser offense.

Felony/misdemeanor

Charge

Outcome

Date (Month/Year)

Est.

Est.

Est.

Est.

Enter your Social Security Number before going to the next page

Page 60

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 20 - Police Record - (CONTINUED)

Entry #2

Entry #2

(d)Were you sentenced as a result of this offense?

YES (If YES, complete (d.1))

NO (If NO, complete (d.2))

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(d.1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a description of the sentence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you sentenced to imprisonment for a term exceeding 1 year?

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

Were you incarcerated as a result of that sentence for not less than 1 year?

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

If the conviction resulted in imprisonment, provide the dates that you

 

Not Applicable

From Date

(Month/Year)

To Date (Month/Year)

 

Present

 

 

 

 

actually were incarcerated.

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If conviction resulted in probation or parole, provide the dates of

 

Not Applicable

From Date

(Month/Year)

To Date (Month/Year)

 

Present

 

 

probation or parole.

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(d.2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide explanation.

Enter your Social Security Number before going to the next page

Page 61

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 20 - Police Record - (CONTINUED)

20.2 Other than those offenses already listed, have you EVER had the following happen to you?

YES

NO (If NO, proceed to 20.3)

-Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/ domestic partner, or someone with whom you share a child in common?

Entry #1

Provide the date of offense. (Month/Year)

 

 

Provide a description of the specific nature of the offense.

 

 

 

 

 

 

Est.

 

 

 

 

 

(a)Did this offense involve any of the following?

YES NO

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom you share a child in common?

Provide the name of the court.

Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser offense separately.

Felony/misdemeanor

Charge

Outcome

Date (Month/Year)

Est.

Est.

Est.

Est.

(b)Were you sentenced as a result of these charges?

 

YES (If YES, complete (b.1))

NO (If NO, complete (b.2))

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a description of the sentence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you sentenced to imprisonment for a term exceeding 1 year?

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you incarcerated as a result of that sentence for not less than 1 year?

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the conviction resulted in imprisonment, provide the dates that you

 

Not Applicable

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

actually were incarcerated.

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If conviction resulted in probation or parole, provide the dates of

 

Not Applicable

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

probation or parole.

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?

 

 

 

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 62

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 20 - Police Record - (CONTINUED)

Entry #2

Provide the date of offense. (Month/Year)

 

 

Provide a description of the specific nature of the offense.

 

 

 

 

 

 

Est.

 

 

 

 

 

(a)Did this offense involve any of the following?

YES NO

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse or legally recognized civil union/domestic partner, former spouse or legally recognized civil union/domestic partner, or someone with whom you share a child in common?

Provide the name of the court.

Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City

County

State

Zip Code

Country

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser offense separately.

Felony/misdemeanor

Charge

Outcome

Date (Month/Year)

Est.

Est.

Est.

Est.

(b)Were you sentenced as a result of these charges?

 

YES (If YES, complete (b.1))

NO (If NO, complete (b.2))

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a description of the sentence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did this offense involve any of the following?

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you incarcerated as a result of that sentence for not less than 1 year?

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the conviction resulted in imprisonment, provide the dates that you

 

Not Applicable

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

actually were incarcerated.

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If conviction resulted in probation or parole, provide the dates of

 

Not Applicable

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

probation or parole.

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?

 

 

 

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 63

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 20 - Police Record - (CONTINUED)

20.3

Is there currently a domestic violence protective order or restraining order issued against you?

YES

NO (If NO, proceed to Section 21)

 

 

Complete the following if you responded 'Yes' to currently having a domestic violence protective order or restraining order issued against you?

Entry #1

Provide explanation.

Provide the date the order was issued. (Month/Year)

 

 

Provide the name of the court or agency that issued the order.

 

 

 

 

 

 

Est.

 

 

 

 

 

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

State

 

 

Zip Code

Country

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

Provide the date the order was issued. (Month/Year)

 

 

Provide the name of the court or agency that issued the order.

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

State

 

 

Zip Code

Country

 

 

 

 

 

 

 

Entry #3

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

Provide the date the order was issued. (Month/Year)

 

 

Provide the name of the court or agency that issued the order.

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

State

 

 

Zip Code

Country

 

 

 

 

 

 

 

Entry #4

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

Provide the date the order was issued. (Month/Year)

 

 

Provide the name of the court or agency that issued the order.

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City

State

Zip Code

Country

Enter your Social Security Number before going to the next page

Page 64

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 21 - Illegal Use of Drugs and Drug Activity

Form approved: OMB No. 3206 0258

You are required to answer the questions. We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity not in accordance with Federal laws, even though permissible under state laws.

21.1

In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or

YES

NO (If NO, proceed to 21.2)

 

controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise

 

 

 

 

consuming any drug or controlled substance.

 

 

 

 

Complete the following if you answered 'Yes' to in the last seven (7) years having illegally used a drug or controlled substance.

 

 

 

 

Entry #1

 

 

Provide the type of drug or controlled substance.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Steroids (Such as the clear, juice, etc.)

Other (Provide explanation)

Provide an estimate of the month and year of first use. (Month/Year)

Est.

Provide an estimate of the month and year of most recent use. (Month/Year)

Est.

Provide nature of use, frequency, and number of times used.

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in

YES

NO

a position directly and immediately affecting the public safety?

 

 

 

 

 

Was your use while possessing a security clearance?

YES

NO

 

 

 

 

Do you intend to use this drug or controlled substance in the future?

YES

NO

 

Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.

Entry #2

Provide the type of drug or controlled substance.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Ketamine (Such as special K, jet, etc.)

 

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

 

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

 

 

Inhalants (Such as toluene, amyl nitrate, etc.)

Other

(Provide explanation)

 

 

 

 

 

 

 

 

 

Provide an estimate of the month

Provide an estimate of the month and

 

Provide nature of use, frequency, and number of times used.

and year of first use. (Month/Year)

year of most recent use. (Month/Year)

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in

YES

NO

a position directly and immediately affecting the public safety?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was your use while possessing a security clearance?

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you intend to use this drug or controlled substance in the future?

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.

Enter your Social Security Number before going to the next page

Page 65

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 21 - Illegal Use of Drugs and Drug Activity - (CONTINUED)

21.2

In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation,

YES

NO (If NO, proceed to 21.3)

 

trafficking, production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?

 

 

Complete the following if you answered 'Yes' to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance.

Entry #1

Provide the type of drug or controlled substance.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Steroids (Such as the clear, juice, etc.)

Other (Provide explanation)

 

 

Provide an estimate of the month and

Provide an estimate of the month and year

 

 

Provide the nature and frequency of activity.

 

 

year of first involvement. (Month/Year)

of most recent involvement. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) why you engaged in the activity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a

YES

NO

 

 

position directly and immediately affecting the public safety?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was your involvement while possessing a security clearance?

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

Do you intend to engage in this activity in the future?

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the type of drug or controlled substance.

 

 

 

 

 

 

 

 

 

 

Cocaine or crack cocaine (Such as rock, freebase, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

 

 

THC (Such as marijuana, weed, pot, hashish, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

 

 

Ketamine (Such as special K, jet, etc.)

 

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

 

 

 

 

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

 

 

 

 

 

Inhalants (Such as toluene, amyl nitrate, etc.)

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide an estimate of the month and

Provide an estimate of the month and year

 

 

Provide the nature and frequency of activity.

 

year of first involvement. (Month/Year)

of most recent involvement. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) why you engaged in the activity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a

YES

NO

 

position directly and immediately affecting the public safety?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was your involvement while possessing a security clearance?

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

Do you intend to engage in this activity in the future?

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

Provide explanation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 66

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 21 - Illegal Use of Drugs and Drug Activity - (CONTINUED)

21.3

In the last seven (7) years, have you illegally used or otherwise been involved with a drug or controlled

YES

NO (If NO, proceed to 21.4)

 

 

substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously listed?

Complete the following if you responded 'Yes' to having in the last seven (7) years, illegally used, or otherwise been involved with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously listed.

Entry #1

Provide a description of the drugs or controlled substances used and your involvement.

Provide the dates of involvement/use.

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

Provide an estimate of the number of times you used and/or were involved with this drug or controlled substance while employed in this capacity.

Entry #2

Provide a description of the drugs or controlled substances used and your involvement.

Provide the dates of involvement/use.

From Date (Month/Year)

To Date

(Month/Year)

 

Present

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide an estimate of the number of times you used and/or were involved with this drug or controlled substance while employed in this capacity.

Enter your Social Security Number before going to the next page

Page 67

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 21 - Illegal Use of Drugs and Drug Activity - (CONTINUED)

21.4

In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of

YES

NO (If NO, proceed to 21.5)

 

 

whether or not the drugs were prescribed for you or someone else?

Complete the following if you responded 'Yes' to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless of whether the drugs were prescribed for you or someone else.

Entry #1

Provide the name of the prescription drug that you misused.

Provide the dates of involvement in the above.

From Date (Month/Year)

To Date

(Month/Year)

 

Present

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a

YES

NO

position directly and immediately affecting the public safety?

 

 

 

 

 

Was your involvement while possessing a security clearance?

YES

NO

Entry #2

Provide the name of the prescription drug that you misused.

Provide the dates of involvement in the above.

From Date (Month/Year)

To Date

(Month/Year)

 

Present

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a

YES

NO

position directly and immediately affecting the public safety?

 

 

 

 

 

Was your involvement while possessing a security clearance?

YES

NO

Enter your Social Security Number before going to the next page

Page 68

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 21 - Illegal Use of Drugs and Drug Activity - (CONTINUED)

21.5

In the last seven (7) years have you been ordered, advised, or asked to seek counseling or

YES

NO (If NO, proceed to 21.6)

 

 

treatment as a result of your illegal use of drugs or controlled substances?

Complete the following if you responded 'Yes' to In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances.

Entry #1

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? (Select all that apply):

An employer, military commander, or employee assistance program

A court official / judge

 

A medical professional

I have not been ordered, advised, or asked to seek

 

 

 

A mental health professional

counseling or treatment by any of the above.

 

 

 

 

 

 

Provide explanation

 

 

 

 

 

Did you take action to receive counseling or treatment?

YES (If YES, complete (b))

NO (If NO, complete (a))

(a)You have indicated that you did not receive treatment. Provide explanation.

(b)You have indicated that you did receive treatment.

Provide the type of drug or controlled substance for which you were treated.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Steroids (Such as the clear, juice, etc.)

Other (Provide explanation)

Provide the name of the treatment provider.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

 

Street

City

 

 

 

 

 

 

State

 

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a telephone number for the

Extension

 

International or DSN

 

Provide the dates of treatment.

 

 

 

 

 

 

treatment provider.

 

 

phone number

 

From Date (Month/Year) To Date (Month/Year)

 

Present

 

 

 

Day

 

 

Night

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment?

YES

 

NO

 

 

 

(Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 69

A court official / judge
I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 21 - Illegal Use of Drugs and Drug Activity - (CONTINUED)

Complete the following if you responded 'Yes' to In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances.

Entry #2

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? (Select all that apply):

An employer, military commander, or employee assistance program

A medical professional

A mental health professional

Provide explanation

Did you take action to receive counseling or treatment?

YES (If YES, complete (b))

NO (If NO, complete (a))

(a)You have indicated that you did not receive treatment. Provide explanation.

(b)You have indicated that you did receive treatment.

Provide the type of drug or controlled substance for which you were treated.

 

 

Cocaine or crack cocaine (Such as rock, freebase, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Ketamine (Such as special K, jet, etc.)

 

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

 

 

 

 

 

 

Provide the name of the treatment provider.

 

 

 

 

Last name

First name

 

 

 

 

 

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a telephone number for the

Extension

 

International or DSN

treatment provider.

 

 

phone number

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

Provide the dates of treatment.

From Date (Month/Year) To Date (Month/Year)

 

Present

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment?

YES

NO

 

(Provide explanation)

 

Enter your Social Security Number before going to the next page

Page 70

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 21 - Illegal Use of Drugs and Drug Activity - (CONTINUED)

21.6

In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your

YES

NO (If NO, proceed to Section 22)

 

 

use of a drug or controlled substance?

Complete the following if you responded 'Yes' to In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance.

Entry #1

Provide the type of drug or controlled substance for which you were treated.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Ketamine (Such as special K, jet, etc.)

 

Steroids (Such as the clear, juice, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Other

(Provide explanation)

 

 

 

 

 

 

Provide the name of the treatment provider.

 

 

 

 

Last name

First name

 

 

 

 

 

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a telephone number for the

Extension

treatment provider.

 

International or DSN phone number

Day Night

Provide the dates of treatment.

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment?

YES

NO

 

(Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

Provide the type of drug or controlled substance for which you were treated.

 

 

 

 

 

Cocaine or crack cocaine (Such as rock, freebase, etc.)

 

 

 

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

 

 

THC (Such as marijuana, weed, pot, hashish, etc.)

 

 

 

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

 

 

Ketamine (Such as special K, jet, etc.)

 

 

 

 

Steroids (Such as the clear, juice, etc.)

 

 

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

 

 

 

Inhalants (Such as toluene, amyl nitrate, etc.)

 

 

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Other

(Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

Provide the name of the treatment provider.

 

 

 

 

 

 

 

Last name

First name

 

 

 

 

 

 

 

 

 

 

Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

 

 

 

State

Zip Code

Country

Provide a telephone number for the

Extension

treatment provider.

 

 

International or DSN phone

Provide the dates of treatment.

 

 

 

 

 

 

number

 

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

 

 

 

 

 

Day

 

Night

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment?

YES

NO

 

(Provide explanation)

 

Enter your Social Security Number before going to the next page

Page 71

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 22 - Use of Alcohol

22.1 In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your YES NO (If NO, proceed to 22.2) professional or personal relationships, your finances, or resulted in intervention by law enforcement/public

safety personnel?

Complete the following if you responded 'Yes' to your alcohol use having had a negative impact on your work performance, your professional or personal relationships, your finances, or resulted in intervention by law enforcement/public safety personnel.

Entry #1

Provide the month/year when this negative impact occurred.

Provide dates of involvement or use.

 

 

 

From Date (Month/Year)

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

 

Est.

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide an explanation of the circumstances and the negative impact.

 

 

 

 

 

 

 

Provide circumstances.

Provide negative impact.

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

Provide the month/year when this negative impact occurred.

Provide dates of involvement or use.

 

 

 

 

From Date (Month/Year)

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

 

 

 

Est.

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide an explanation of the circumstances and the negative impact.

 

 

 

 

 

 

 

 

Provide circumstances.

Provide negative impact.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #3

Provide the month/year when this negative impact occurred.

Provide dates of involvement or use.

 

 

 

From Date (Month/Year)

From Date (Month/Year)

To Date (Month/Year)

 

Present

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide an explanation of the circumstances and the negative impact.

 

 

 

 

 

 

 

Provide circumstances.

Provide negative impact.

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #4

 

Provide the month/year when this negative impact occurred.

Provide dates of involvement or use.

 

 

 

 

From Date (Month/Year)

From Date (Month/Year)

 

To Date (Month/Year)

 

Present

 

 

 

 

 

Est.

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide an explanation of the circumstances and the negative impact.

 

 

 

 

 

 

 

 

Provide circumstances.

Provide negative impact.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 72

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 22 - Use of Alcohol - (CONTINUED)

Form approved: OMB No. 3206 0258

22.2

In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a

YES

NO (If NO, proceed to 22.3)

 

 

result of your use of alcohol?

Complete the following if you responded 'Yes' to having been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol.

Entry #1

Did you take action to receive counseling or treatment?

YES (If YES, complete (b))

NO (If NO, complete (a))

(a)You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment. Provide explanation.

(b)You responded 'Yes' to having taken action to seek counseling or treatment.

Provide the dates of counseling or treatment.

 

 

Provide the name of the individual counselor or treatment provider.

From Date (Month/Year)

 

Est.

To Date (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

 

Street

City

 

 

 

 

State

 

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment program?

YES

NO

 

(Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you take action to receive counseling or treatment?

 

 

 

 

 

 

 

 

YES (If YES, complete (b))

NO (If NO, complete (a))

(a)You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment. Provide explanation.

(b)You responded 'Yes' to having taken action to seek counseling or treatment.

Provide the dates of counseling or treatment.

 

 

Provide the name of the individual counselor or treatment provider.

From Date (Month/Year)

 

Est.

To Date (Month/Year)

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

 

 

 

 

State

 

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

Day

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment program?

YES

NO

 

 

(Provide explanation)

 

 

 

Enter your Social Security Number before going to the next page

Page 73

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 22 - Use of Alcohol - (CONTINUED)

22.3 In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of alcohol?

YES

NO (If NO, proceed to 23)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of counseling or treatment.

 

 

 

 

 

 

Provide the name of the individual counselor or treatment provider.

 

From Date (Month/Year)

Est.

 

To Date (Month/Year)

 

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the full address of the counseling or treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

 

 

 

Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment program?

 

 

YES

 

NO

 

 

(Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of counseling or treatment.

 

 

 

 

 

 

Provide the name of the individual counselor or treatment provider.

 

From Date (Month/Year)

Est.

To Date (Month/Year)

 

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the full address of the counseling or treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

Street

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

 

 

 

Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you successfully complete the treatment program?

 

 

YES

 

NO

 

 

(Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 74

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 23 - Investigations and Clearance Record

Form approved: OMB No. 3206 0258

23.1

Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you

YES

NO (If NO, proceed to 23.2)

 

 

 

a security clearance eligibility/access?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete the following if you responded 'Yes' to the U.S. Government (or a foreign government) having investigated your background and/or having

 

granted you a security clearance eligibility/access.

 

 

 

 

 

 

 

 

 

 

 

 

Entry #1

 

 

 

 

 

Provide the investigating agency:

 

 

 

 

 

 

 

U.S. Department of Defense

 

U.S. Department of Homeland Security

 

 

 

 

 

 

 

 

 

 

 

U.S. Department of State

 

Foreign government (Provide name of government)

 

 

 

 

 

 

 

 

 

 

 

U.S. Office of Personnel Management

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

Federal Bureau of Investigation

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

U.S. Department of Treasury (Provide name of bureau)

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

 

 

Date the investigation was completed (Month/Year)

 

I don't know

 

 

Est.

 

 

Provide the date clearance eligibility/access was granted. (Month/Year)

 

I don't know

 

 

Est.

 

 

 

Provide the level of clearance eligibility/access granted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

Q

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confidential

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secret

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Top Secret

 

 

Issued by foreign country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sensitive Compartmented Information (SCI)

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the investigating agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Department of Defense

 

 

 

 

 

U.S. Department of Homeland Security

 

 

 

 

 

 

 

U.S. Department of State

 

 

 

Foreign government (Provide name of government)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Office of Personnel Management

 

 

 

 

I don't know

 

 

 

 

 

 

 

Federal Bureau of Investigation

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Department of Treasury (Provide name of bureau)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date the investigation was completed (Month/Year)

 

 

 

 

 

 

I don't know

Provide the date clearance eligibility/access was granted. (Month/Year)

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the level of clearance eligibility/access granted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

Q

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confidential

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secret

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Top Secret

 

 

Issued by foreign country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sensitive Compartmented Information (SCI)

 

 

Other (Provide explanation)

 

 

Enter your Social Security Number before going to the next page

Page 75

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 23 - Investigations and Clearance Record - (CONTINUED)

23.2

Have you EVER had a security clearance eligibility/access authorization denied, suspended, or

YES

NO (If NO, proceed to 23.3)

 

revoked? (Note: An administrative downgrade or administrative termination of a security clearance is

 

 

 

not a revocation.)

Complete the following if you responded 'Yes' to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.

Entry #1

Provide the date security clearance eligibility/access authorization was denied, suspended or revoked. (Month/Year)

Est.

Provide the name of the agency that took the action.

Provide an explanation of the circumstances of the denial,suspension or revocation action.

Entry #2

Provide the date security clearance eligibility/access authorization was denied, suspended or revoked. (Month/Year)

Est.

Provide the name of the agency that took the action.

Provide an explanation of the circumstances of the denial,suspension or revocation action.

23.3 Have you EVER been debarred from government employment?

YES

NO (If NO, proceed to Section 24)

 

Complete the following if you responded 'Yes' to having EVER been debarred from government employment.

Entry #1

Provide the name of the government agency taking debarment action.

Provide the date the debarment occurred.

(Month/Year)

Est.

Provide an explanation of the circumstances of the debarment.

Entry #2

Provide the name of the government agency taking debarment action.

Provide the date the debarment occurred.

(Month/Year)

Est.

Provide an explanation of the circumstances of the debarment.

Enter your Social Security Number before going to the next page

Page 76

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 24 - Financial Record

24.1

In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?

YES

NO (If NO, proceed to 24.2)

Complete the following if you responded 'Yes' to in the last seven (7) years having filed a petition under any chapter of the bankruptcy code.

Entry #1

Select the applicable bankruptcy petition type.

 

Provide the bankruptcy court docket/account number.

 

Chapter 7

Chapter 11

Chapter 12

Chapter 13

 

 

 

 

 

 

 

 

 

 

 

Provide the date bankruptcy was

 

Provide the date of bankruptcy

 

Provide the total amount (in U.S.

filed. (Month/Year)

 

 

discharge. (Month/Year)

Not Applicable

dollars) involved in the bankruptcy.

 

Est.

 

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name debt is recorded under.

 

 

 

 

 

 

Last name

 

 

First name

 

Middle name

Suffix

Provide the name of the court involved.

Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

(a)If Chapter 13 or Chapter 12 previously selected: Provide the name of the trustee for this bankruptcy.

Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

Street

 

 

City

 

State

 

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you discharged of all debts claimed in the bankruptcy?

 

 

 

YES (Provide explanation)

NO (Provide explanation)

 

 

 

 

 

 

 

 

 

 

Provide Explanation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

Select the applicable bankruptcy petition type.

 

Provide the bankruptcy court docket/account number.

 

 

Chapter 7

Chapter 11

Chapter 12

Chapter 13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the date bankruptcy was

 

Provide the date of bankruptcy

 

 

 

Provide the total amount (in U.S.

 

filed. (Month/Year)

 

 

discharge. (Month/Year)

 

Not Applicable

dollars) involved in the bankruptcy.

 

 

 

 

Est.

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name debt is recorded under.

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

Middle name

Suffix

 

Provide the name of the court involved.

Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

(a)If Chapter 13 or Chapter 12 previously selected: Provide the name of the trustee for this bankruptcy.

Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

 

 

 

 

 

 

 

Were you discharged of all debts claimed in the bankruptcy?

 

YES (Provide explanation)

NO (Provide explanation)

 

 

 

Provide Explanation.

Enter your Social Security Number before going to the next page

Page 77

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 24 - Financial Record - (CONTINUED)

24.2

In the last seven(7) years have you failed to meet financial obligations due to gambling?

YES

NO (If NO, proceed to 24.3)

Complete the following if you responded 'Yes' to having failed to meet financial obligations due to gambling.

Entry #1

Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.

From Date (Month/Year)

To Date (Month/Year)

Est.

Present

Est.

Provide a description of your financial problems due to gambling. If you have taken any action(s) to rectify your financial problems due to gambling, provide a description of your actions. If you have not taken any action(s), provide explanation.

Entry #2

Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.

From Date (Month/Year)

To Date (Month/Year)

Est.

Present

Est.

Provide a description of your financial problems due to gambling. If you have taken any action(s) to rectify your financial problems due to gambling, provide a description of your actions. If you have not taken any action(s), provide explanation.

24.3

In the last seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law

YES

NO (If NO, proceed to 24.4)

 

 

or ordinance?

Complete the following if you responded 'Yes' to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.

Entry #1

Did you fail to file, pay as required, or both? Provide the year you failed to file or pay your Federal, state, or other taxes.

File

Pay

Both

 

Est.

 

 

 

 

 

Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency

Provide the type of taxes you failed to file or

 

 

 

to which you failed to file or pay taxes.

pay (such as property, income, sales, etc.).

Provide the amount (in U.S. dollars) of the taxes.

Provide date satisfied. (Month/Year)

Est.

Not Applicable Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.

Entry #2

Did you fail to file, pay as required, or both?

Provide the year you failed to file or pay your Federal, state, or other taxes.

File

Pay

Both

 

Est.

 

 

 

 

Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency

Provide the type of taxes you failed to file or

 

 

 

to which you failed to file or pay taxes.

pay (such as property, income, sales, etc.).

Provide the amount (in U.S. dollars) of the taxes.

 

Provide date satisfied. (Month/Year)

 

Est.

 

 

 

 

Not Applicable Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.

Enter your Social Security Number before going to the next page

Page 78

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 24 - Financial Record - (CONTINUED)

24.4

In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of

YES

NO (If NO, proceed to 24.5)

 

 

agreement for a travel or credit card provided by your employer?

Complete the following if you responded 'Yes' to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer.

Entry #1

Provide the name of the agency or company.

Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide the reason(s) for the counseling, warning, or disciplinary action.

Provide the amount (in U.S. dollars) of violation.

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any action(s) provide explanation.

Est.

Entry #2

Provide the name of the agency or company.

Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide the reason(s) for the counseling, warning, or disciplinary action.

Provide the amount (in U.S. dollars) of violation.

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any action(s) provide explanation.

Est.

24.5

Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to

YES

NO (If NO, proceed to 24.6)

 

 

resolve an inability to meet financial obligations?

Complete the following if you responded 'Yes' to currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve an inability to meet financial obligations.

Entry #1

Provide explanation.

Provide the name of the credit counseling organization or resource.

Provide the telephone number of the credit counseling organization.

Telephone number

Extension

International or DSN phone number

 

 

Day

Night

 

 

 

 

 

 

Provide the location of the credit counseling organization.

City

State

As a result of this counseling, provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken any action(s), provide explanation.

Entry #2

Provide explanation.

Provide the name of the credit counseling organization or resource.

Provide the telephone number of the credit counseling organization.

Telephone number

Extension

International or DSN phone number

 

 

Day

Night

 

 

 

 

 

 

Provide the location of the credit counseling organization.

City

State

As a result of this counseling, provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page

Page 79

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 24 - Financial Record - (CONTINUED)

24.6

Other than previously listed, have any of the following happened to you? (You will be asked to provide

YES

NO (If NO, proceed to 24.7)

 

details about each financial obligation that pertains to the items identified below)

 

 

 

-You are currently delinquent on alimony or child support payments.

-In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

-In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

-You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

Entry #1

Provide the name of agency/organization/individual to which debt is/was owed.

Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to 24.7)

 

You are currently delinquent on alimony or child support payments.

In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

Provide the date the financial

 

Provide date the financial issue

 

Provide the name of the court involved.

issue began. (Month/Year)

 

was resolved. (Month/Year)

Not Resolved

 

 

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page

Page 80

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 24 - Financial Record - (CONTINUED)

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

Entry #2

Provide the name of agency/organization/individual to which debt is/was owed.

Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to 24.7)

 

You are currently delinquent on alimony or child support payments.

In the last seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

Provide the date the financial

 

Provide date the financial issue

 

Provide the name of the court involved.

issue began. (Month/Year)

 

was resolved. (Month/Year)

Not Resolved

 

 

 

Est.

 

Est.

 

 

 

 

 

 

 

 

 

Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page

Page 81

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 24 - Financial Record - (CONTINUED)

24.7

Other than previously listed, have any of the following happened?

YES

NO (If NO, proceed to Section 25)

 

 

- In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

- In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

- In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

- In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

- In the last seven (7) years, you were evicted for non-payment?

- In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?

- In the last seven (7) years, you were over 120 days delinquent on any debt not

previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

- You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

Entry #1

Provide the name of agency/organization/individual to which debt is/was owed.

Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to Section 25)

In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you were evicted for non-payment?

In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?

In the last seven (7) years, you were over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.

Provide the date the financial issue began. (Month/Year)

Provide date the financial issue was resolved. (Month/Year)

Est.

Not Resolved

Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page

Page 82

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 24 - Financial Record - (CONTINUED)

Form approved: OMB No. 3206 0258

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

Entry #2

Provide the name of agency/organization/individual to which debt is/was owed.

Did/does this financial issue include any of the following? (Select all that apply)

YES

NO (If NO, proceed to Section 25)

In the last seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

In the last seven (7) years, you were evicted for non-payment?

In the last seven (7) years, you had wages, benefits, or assets garnished or attached for any reason?

In the last seven (7) years, you were over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.

Provide the date the financial issue began. (Month/Year)

Provide date the financial issue was resolved. (Month/Year)

Est.

Not Resolved

Est.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s), provide explanation.

Enter your Social Security Number before going to the next page

Page 83

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 25 - Use of Information Technology Systems

Form approved: OMB No. 3206 0258

We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions ask about your use of information technology systems. Information technology systems include all related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection of information.

25.1

In the last seven (7) years have you illegally or without proper authorization accessed or attempted to

YES

NO (If NO, proceed to 25.2)

 

access any information technology system?

 

 

 

Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into any information technology system.

Entry #1

Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Entry #2

Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

25.2

In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or

YES

NO (If NO, proceed to 25.3)

 

denied others access to information residing on an information technology system or attempted any of the

 

 

 

above?

Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or denied others access to information residing on an information technology system or attempted any of the above.

Entry #1

Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Entry #2

Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Enter your Social Security Number before going to the next page

Page 84

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 25 - Use of Information Technology Systems - (CONTINUED)

25.3

In the last seven (7) years have you introduced, removed, or used hardware, software, or media in

YES

NO (If NO, proceed to Section 26)

 

 

connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted any of the above?

Complete the following if you responded 'Yes' to having in the last seven (7) years introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted any of the above.

Entry #1

Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Entry #2

Provide the date of the incident. (Month/Year)

Provide a description of the nature of the incident or offense.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Enter your Social Security Number before going to the next page

Page 85

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 26 - Involvement in Non-Criminal Court Actions

In the last seven (7) years, have you been a party to any public record civil court action not listed elsewhere on

YES

NO (If NO, proceed to Section 27)

this form?

 

 

Complete the following if you responded 'Yes' to having been a party to any public record civil court action(s) not listed elsewhere on this form in the last seven (7) years.

Entry #1

Provide the date of the civil action. (Month/Year)

 

Provide the court name.

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

Street

City

State

Zip Code

Country

 

Provide details of the nature of the action.

Provide a description of the results of the action.

Provide the name(s) of the principal parties involved in the court action.

Entry #2

Provide the date of the civil action. (Month/Year)

 

Provide the court name.

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

 

Street

City

State

Zip Code

Country

 

Provide details of the nature of the action.

Provide a description of the results of the action.

Provide the name(s) of the principal parties involved in the court action.

Enter your Social Security Number before going to the next page

Page 86

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 27 - Association Record

Form approved: OMB No. 3206 0258

The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment, security, or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.

27.1

Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an

YES

NO (If NO, proceed to 27.2)

 

 

awareness of the organization's dedication to that end, or with the specific intent to further such activities?

Complete the following if you responded 'YES' to being or ever having been a member of an organization dedicated to terrorism, either with an awareness of the organization's dedication to that end, or with the specific intent to further such activities.

Entry #1

Provide the full name of the organization.

Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

 

 

 

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of your involvement with the organization.

Provide all positions held in the organization, if any.

No positions held

 

 

From Date (Month/Year)

 

To Date (Month/Year)

Present

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide all contributions made to the

No contributions made

Provide a description of the nature of and reasons for your involvement with the

 

 

organization, if any.

 

 

 

 

 

organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

Provide the full name of the organization.

Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

City

State

Zip Code

Country

Provide the dates of your involvement with the organization.

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

 

Est.

 

 

 

Provide all positions held in the organization, if any.

No positions held

Provide all contributions made to the organization, if any.

No contributions made

Provide a description of the nature of and reasons for your involvement with the organization.

Enter your Social Security Number before going to the next page

Page 87

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 27 - Association Record - (CONTINUED)

27.2

Have you EVER knowingly engaged in any acts of terrorism?

YES

NO (If NO, proceed to 27.3)

 

 

 

Complete the following if you responded 'Yes' to EVER having knowingly engaged in any acts of terrorism.

 

 

 

 

 

Entry #1

 

 

Describe the nature and reasons for the activity.

Provide the dates for any such activities.

From Date (Month/Year)

 

To Date (Month/Year)

 

Est.

 

 

 

 

Present Est.

Entry #2

Describe the nature and reasons for the activity.

Provide the dates for any such activities.

From Date (Month/Year)

 

To Date (Month/Year)

 

Est.

 

 

 

 

Present Est.

27.3

Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by

YES

NO (Proceed to 27.4)

 

 

force?

Complete the following if you responded 'Yes' to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force.

Entry #1

Provide the reason(s) for advocating acts of terrorism.

Provide the dates of advocating acts of terrorism.

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

 

Est.

 

 

 

Entry #2

Provide the reason(s) for advocating acts of terrorism.

Provide the dates of advocating acts of terrorism.

From Date (Month/Year)

 

To Date (Month/Year)

 

Est.

 

 

 

 

Present Est.

Enter your Social Security Number before going to the next page

Page 88

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 27 - Association Record - (CONTINUED)

27.4

Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow

YES

NO (If NO, proceed to 27.5)

 

 

the United States Government, and which engaged in activities to that end with an awareness of the organization's dedication to that end or with the specific intent to further such activities?

Complete the following if you responded 'Yes' to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States Government, and which engaged in activities to that end with an awareness of the organization's dedication to that end or with the specific intent to further such activities.

Entry #1

Provide the full name of the organization.

Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

 

 

 

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of your involvement with the organization.

Provide all positions held in the organization, if any.

No positions held

From Date (Month/Year)

 

To Date (Month/Year)

Present

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide all contributions made to the

No contributions made

Provide a description of the nature of and reasons for your involvement with the

organization, if any.

 

 

 

 

 

organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

Provide the full name of the organization.

Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

 

 

 

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of your involvement with the organization.

Provide all positions held in the organization, if any.

No positions held

From Date (Month/Year)

 

To Date (Month/Year)

Present

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide all contributions made to the

No contributions made

Provide a description of the nature of and reasons for your involvement with the

organization, if any.

 

 

 

 

 

organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 89

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 27 - Association Record - (CONTINUED)

27.5

Have you EVER been a member of an organization that advocates or practices commission of acts of force

YES

NO (If NO, proceed to 27.6)

 

 

or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to further such action?

Complete the following if you responded 'Yes' to being or EVER having been a member of an organization that advocates or practices commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the specific intent to further such action.

Entry #1

Provide the full name of the organization.

Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

 

 

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of your involvement with the organization.

 

Provide all positions held in the organization, if any.

No positions held

 

 

From Date (Month/Year)

To Date (Month/Year)

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide all contributions (in U.S. dollars)

No contributions made

Provide a description of the nature of and reasons for your involvement with the

 

 

made to the organization, if any.

 

 

 

 

organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

Provide the full name of the organization.

Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street

 

 

City

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the dates of your involvement with the organization.

 

Provide all positions held in the organization, if any.

No positions held

 

From Date (Month/Year)

To Date (Month/Year)

Present

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide all contributions (in U.S. dollars)

No contributions made

Provide a description of the nature of and reasons for your involvement with the

 

made to the organization, if any.

 

 

 

 

organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 90

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 27 - Association Record - (CONTINUED)

Form approved: OMB No. 3206 0258

27.6

Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?

YES

NO (If NO, proceed to 27.7)

 

 

 

Complete the following if you responded 'Yes' to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.

 

 

 

Entry #1

 

 

Describe the nature and reasons for the activity.

Provide the dates of such activities.

From Date (Month/Year)

 

To Date (Month/Year)

 

Est.

 

 

 

 

Present Est.

Entry #2

Describe the nature and reasons for the activity.

Provide the dates of such activities.

From Date (Month/Year)

 

To Date (Month/Year)

 

Est.

 

 

 

 

Present Est.

27.7

Have you EVER associated with anyone involved in activities to further terrorism?

YES

NO

 

 

 

 

 

Complete the following if you responded 'Yes' to having EVER associated with anyone involved in activities to further terrorism.

 

 

 

 

 

 

 

 

Entry #1

 

 

 

 

 

 

 

 

Provide explanation.

 

 

 

Entry #2

Provide explanation.

Enter your Social Security Number before going to the next page

Page 91

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Additional Comments

Form approved: OMB No. 3206 0258

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 further affirm that, to the best of my knowledge, I have not included any classified information herein. 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, falsifying, or including classified information may have a negative effect on my employment prospects, or job status, or my removal and debarment from Federal service.

Signature (Sign in ink)

Date signed (mm/dd/yyyy)

Page 92

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation or reinvestigation to obtain any information relating to my activities, conduct and character from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of information. This information may include, but is not limited to, current and historic academic, residential, achievement, performance, attendance, disciplinary, employment, criminal, financial and credit information, and publicly available social media information. I authorize the Federal agency conducting my investigation, or reinvestigation, or performing continuous vetting, to disclose the record of investigation to the requesting agency for the purpose of making a determination of suitability or eligibility for a public trust position.

I Understand that, for these purposes, publicly available social media information includes any electronic social media information that has been published or broadcast for public consumption, is available on request to the public, is accessible on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully accessible to the public. I further understand that this authorization does not require me to provide passwords; log into a private account; or take any action that would disclose non-publicly available social media information.

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.

I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of Investigation, the Department of Defense, the Department of Homeland Security, and the Department of State, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in, a public trust position, in accordance with 5 U.S.C. 9101. I understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes provided in this Standard Form 85P, and that it may be disclosed by the Government only as authorized by law.

I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and analyses, which will be maintained in accordance with the Privacy Act.

Photocopies of this authorization with my signature are valid. This authorization is valid for five(5) years from the date signed or upon termination of my affiliation with the Federal Government, whichever is sooner.

Signature (Sign in ink)

 

Full name (Type or print legibly)

 

Date signed (mm/dd/yyyy)

 

 

 

 

 

 

Other names used

 

 

 

Date of birth

Social Security Number

 

 

 

 

 

 

Current street address Apt. #

City (Country)

State

ZIP Code

Telephone number

 

 

 

 

 

 

Page 93

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

 

UNITED STATES OF AMERICA

Form approved: OMB No. 3206 0258

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT

TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

If you answered “Yes” to Section 5 of the Standard Form 85P with the supplemental SF 85P-S, carefully read this authorization to release information about you, then sign and date.

This is an authorization for the investigator to ask your health practitioner (s) the questions below concerning your mental health consultations. The U.S. government recognizes the critical importance of mental health and advocates proactive management of mental health conditions to support the wellness and recovery of Federal employees and others. The government recognizes that mental health counseling and treatment may provide important support for those who have experienced traumatic events, as well as for those with other mental health conditions.

While most individuals with mental health conditions do not present risks, there may be times when such a condition can affect a person’s suitability for positions of public trust with the Federal government. Seeking or receiving mental health care for personal wellness and recovery may contribute favorably to your suitability determination. Your signature will allow the practitioner (s) to answer only those questions identified below.

Authorization

I am seeking assignment to or retention in a public trust position. As part of the investigation process, I hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my background investigation, reinvestigation, and my health practitioner (s) to provide the information requested below, relating to my mental health consultations.

In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to my health care provider/ entity. I understand that I may revoke this authorization, except to the extent that action has already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I understand the information disclosed pursuant to this authorization is for use by the Federal Government only for purposes provided in the Standard Form 85P and will no longer be subject to the HIPAA Privacy Rule, and that the Federal Government may redisclose the information as authorized by law, subject to Privacy Act safeguards.

Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed or upon termination of my affiliation with the Federal Government, whichever is sooner.

Signature (Sign in ink)

 

Full name (Type or print legibly)

 

Date signed (mm/dd/yyyy)

 

 

 

 

 

 

Other names used

 

 

 

 

Social Security Number

 

 

 

 

 

 

Current street address Apt. #

City (Country)

State

ZIP Code

Telephone number

 

 

 

 

 

 

For Use By Practitioner(s) Only

Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to perform a position of public trust?

YES NO

If so, describe the nature of the condition and the extent and duration of the impairment or treatment.

What is the prognosis?

Dates of treatment?

Signature (Sign in ink)

Practitioner name

Date signed (mm/dd/yyyy)

Page 94

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

 

UNITED STATES OF AMERICA

Form approved: OMB No. 3206 0258

FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION

Disclosure

One or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.

Purpose

The information obtained may be disclosed to other Federal agencies for the above purposes in fulfillment of official responsibilities to the extent that such disclosure is permitted by law. Information from the consumer report will not be used in violation of any applicable Federal or state equal employment opportunity law or regulation.

Authorization

I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my initial background investigation and reinvestigation, or my eligibility for a public trust position, to request, and any consumer reporting agency to provide, such reports for purposes described above.

Note: If you have a security freeze on your consumer or credit report file, we will not be able to access the information necessary to complete your investigation, which can adversely affect your eligibility for a public trust position. To avoid such delays, you should expeditiously respond to any requests made to release the credit freeze for the purposes as described above.

Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I occupy a public trust position.

Print Name

Signature (Sign in ink)

Social Security Number

Date signed (mm/dd/yyyy)

Page 95

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