Washington Details

Have you ever had to fill out Standard Form 85? It's a document that's used by the Department of Defense to collect information on civilians and military personnel. The form is long and detailed, so it can be difficult to know where to start. In this blog post, we'll provide an overview of Standard Form 85, including what information is required and how to complete it. We'll also provide some tips for making the process easier.

This article features specifics of standard form 85. It's advised that you read this info before you decide to start fiddling with the file.

QuestionAnswer
Form NameStandard Form 85
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other names

Form Preview Example

Standard Form 85

Form approved:

Revised December 2013

OMB No. 3206-0261

U.S. Office of Personnel Management

 

5 CFR Parts 731 and 736

 

Questionnaire for Non-Sensitive Positions

Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 5 and the release on Page 6. If you have any questions, call the office that gave you the form.

Purpose of this Form

The U.S. Government conducts background investigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job. Information from this form is used primarily as the basis for this investigation. Complete this form only after a conditional offer of employment has been made.

Giving us the information we ask for is voluntary. However, we may not be able to complete your investigation, or complete it in a timely manner, if you don’t give us each item of information we request. This may affect your placement or employment prospects.

Authority to Request this Information

The U.S. Government is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code; and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.

Your Social Security Number is needed to keep records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

The Investigative Process

Background investigations are conducted using your responses on this form and on your Declaration for Federal Employment (OF 306) to develop information to show whether you are reliable, trustworthy, and of good conduct and character. Your current employer must be contacted as part of the investigation, even if you have previously indicated on applications or other forms that you do not want this.

Instructions for Completing this Form

1.Follow the instructions given to you by the person who gave you the form and any other clarifying instructions furnished by that person to assist you in completion of the form. Find out how many copies of the form you are to turn in. You must sign and date, in black ink, the original and each copy you submit.

2.Type or legibly print your answers in black ink (if your form is not legible, it will not be accepted). You may also be asked to submit your form in an approved electronic format.

3.All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

4.Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, agencies may modify the form consistent with your intent.

5.You must use the State codes (abbreviations) listed on the back of this page when you fill out this form. Do not abbreviate the names of cities or foreign countries.

6.The 5-digit postal ZIP codes are needed to speed the processing of your investigation. The office that provided the form will assist you in completing the ZIP codes.

7.All telephone numbers must include area codes.

8.All dates provided on this form must be in Month/Day/Year or Month/Year format. Use numbers (1-12) to indicate months. For example, June 10, 1978, should be shown as 6/10/78.

9.Whenever "City (Country)" is shown in an address block, also provide in that block the name of the country when the address is outside the United States.

10.If you need additional space to list your residences or employments/self-employments/unemployment or education, you should use a continuation sheet, SF 86A. If additional space is needed to answer other items, use a blank piece of paper. Each blank piece of paper you use must contain your name and Social Security Number at the top of the page.

Final Determination on Your Eligibility

Final determination on your eligibility for a position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made.

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 of up to $10,000, and/or 5 years imprisonment, or both. 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 trustworthiness is a very important consideration in deciding your suitability. Your prospects of placement are better if you answer

all questions truthfully and completely. You will have adequate opportunity to explain any information you give us on the form and to make your comments part of the record.

Disclosure of Information

The information you give us is for the purpose of determining your suitability for Federal employment; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information is governed by the Privacy Act. The agency which requested the investigation and the agency which conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. You may obtain copies of the relevant notices from the person who gave you this form. The information on this form, and information we collect during an investigation may be disclosed without your consent as permitted by the Privacy Act (5 USC 552a(b)) and as follows:

PRIVACY ACT ROUTINE USES

1.To the Department of Justice when: (a) the agency or any component thereof; or

(b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government, is a party to

litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.

2.To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the

Department of Justice has agreed to represent the employee; or (d) the United States Government is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.

3.Except as noted in Question 14, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may

be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order.

4.To any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, 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.

5.To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an employee, or the retention of a security clearance, contract, license, grant, or other benefit. The

other agency or licensing organization may

then make a request supported by

written consent of the individual for the entire

record if it so chooses. No disclosure

will be made unless the information has been determined to be sufficiently reliable to support a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action.

6.To contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged. Such recipients shall be required to comply with the Privacy Act of 1974, as amended.

7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted invasion of personal privacy.

8.To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders or directives.

9.To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained.

10. To the National Archives and Records Administration for records management inspections conducted under 44 USC 2904 and 2906.

11. To the Office of Management and Budget when necessary to the review of private relief legislation.

STATE CODES (ABBREVIATIONS)

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

Florida

FL

Maine

ME

New Hampshire

NH

Rhode Island

RI

Wisconsin

WI

Georgia

GA

Maryland

MD

New Jersey

NJ

South Carolina

SC

Wyoming

WY

American Samoa

AS

District of Columbia

DC

Guam

GU

Northern Marianas

CM

Puerto Rico

PR

Trust Territory

TT

Virgin Islands

VI

 

 

 

 

 

 

PUBLIC BURDEN INFORMATION

Public reporting burden for this collection of information is estimated to average 30 minutes per response, 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 Reports and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send your completed form to this address.

Standard Form 85

 

Revised December 2013

QUESTIONNAIRE FOR

U.S. Office of Personnel Management

NON-SENSITIVE POSITIONS

5 CFR Parts 731 and 736

Form approved: OMB No. 3206-0261

OPM

Codes

Case Number

 

 

USE

 

 

ONLY

 

 

 

 

 

Agency Use Only (Complete items A through K using instructions provided by USOPM)

 

A Type of

 

B Extra

 

 

 

 

C Nature of

 

D Date of

Month

 

Day

 

 

Year

 

 

 

 

 

 

 

 

 

Investigation

 

Coverage

 

 

 

 

Action Code

 

 

Action

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E Geographic

 

 

F Position

 

 

 

G

 

 

 

 

 

H

 

 

 

 

 

Location

 

 

Title

 

 

 

 

SON

 

 

 

 

SOI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I IPAC

 

 

J Accounting Data and/or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Case Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K Requesting

Name and Title

 

 

 

 

Signature

 

Telephone Number

 

 

 

 

Date

 

 

Official

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Persons completing this form should begin with the questions below.

1

FULL

If you have only initials in your name, use them and state (IO).

 

NAME

If you have no middle name, enter "NMN".

 

Last Name

 

First Name

 

 

 

 

-If you are a "Jr.," "Sr.," "II," etc., enter this in the box after your middle name.

Middle Name

Jr., II, etc.

2DATE OF BIRTH

Month Day Year

3PLACE OF BIRTH - Use the two letter code for the State.

City

County

State Country (if not in the United States)

4SOCIAL SECURITY

5OTHER NAMES USED

Give other names you used and the period of time you used them (for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(s)). If the other name is your maiden name, put "nee" in front of it.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

Name

 

 

 

Month/Year

Month/Year

#3

Name

 

 

 

 

Month/Year Month/Year

 

 

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

Name

 

 

 

Month/Year

Month/Year

#4

Name

 

 

 

 

Month/Year Month/Year

 

 

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

SEX (Mark one box)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

CITIZENSHIP

 

 

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. (Answer

 

b

Your Mother’s Maiden Name

 

 

 

 

 

 

 

 

 

 

 

 

items b and d)

 

 

 

 

 

 

 

 

 

 

 

a

 

Mark the box at the right that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am a U.S. citizen, but I was NOT born in the U.S. (Answer items b , c and d)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reflects your current citizenship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

status, and follow its instructions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am not a U.S. citizen. (Answer items b and e)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNITED STATES CITIZENSHIP

If you are a U.S. citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.

 

c

 

 

Naturalization Certificate (Where were you naturalized?)

Court

City

State

Certificate Number

Month/Day/Year Issued

Citizenship Certificate (Where was the certificate issued?) City

State

Certificate Number

Month/Day/Year Issued

State Department Form 240 - Report of Birth Abroad of a Citizen of the United States

Give the date the form was Month/Day/Year Explanation prepared and give an explanation

if needed

U.S. Passport

Passport Number

Month/Day/Year Issued

This may be either a current or previous U.S. Passport.

 

 

 

 

Country

d

DUAL CITIZENSHIP

If you are (or were) a dual citizen of the United States and

 

 

 

 

 

another country, provide the name of that country in the space to

 

 

 

 

the right.

 

 

 

 

 

 

 

 

ALIEN If you are an alien, provide the following information:

 

 

 

 

 

 

 

e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place You

City

State

Date You Entered U.S.

Alien Registration Number

Country(ies) of Citizenship

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

Entered the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

United States:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1

8WHERE YOU HAVE LIVED

List the places where you have lived, beginning with the most recent (#1) and working back 5 years. All periods must be accoun ted for in your list. Be sure to indicate the actual physical location of your residence: do not use a post office box as an address, do not list a permanent address when you were actually living at a school address, etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas.

For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area (do not list people for residences completely outside this 3-year period, and do not list your spouse, former spouses, or other relatives).

 

Month/Year

Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

#1

To

Present

 

 

 

 

 

 

 

 

 

 

 

Name of Person Who Knows You

Street Address

Apt. #

City (Country)

State

ZIP Code

 

Month/Year

Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

#2

To

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

 

Month/Year

Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

#3

To

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

 

Month/Year

Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

#4

To

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

 

Month/Year

Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

#5

To

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

9WHERE YOU WENT TO SCHOOL

List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 5 years. List all College or University degrees and the dates they were received. If all of your education occurred more than 5 years ago, list your most recent education beyond high school, no matter when that education occurred.

-Use one of the following codes in the "Code" block:

1 - High School

2 - College/University/Military College

3 - Vocational/Technical/Trade School

- For correspondence schools and extension classes, provide the address where the records are maintained.

 

Month/Year Month/Year

Code

#1

To

 

 

 

Street Address and City (Country) of School

Name of School

Degree/Diploma/Other

State

Month/Year Awarded

ZIP Code

 

Month/Year Month/Year

Code

#2

To

 

 

 

Street Address and City (Country) of School

Name of School

Degree/Diploma/Other

State

Month/Year Awarded

ZIP Code

 

Month/Year Month/Year

Code

#3

To

 

 

 

Street Address and City (Country) of School

Name of School

Degree/Diploma/Other

State

Month/Year Awarded

ZIP Code

Enter your Social Security Number before going to the next page

Page 2

10YOUR EMPLOYMENT ACTIVITIES

List your employment activities, beginning with the present (#1) and working back 5 years. You should list all full-time work, part-time work, military service, temporary military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 5-year period must be accounted for without breaks, but you need not list employments before your 16th birthday.

Code. Use one of the codes listed below to identify the type of employment:

1

- Active military duty stations

5

- State Government (Non-Federal

7

- Unemployment (Include name of

9 - Other

2

- National Guard/Reserve

 

employment)

 

person who can verify)

 

3

- U.S.P.H.S. Commissioned Corps

6

- Self-employment (Include business name

8

- Federal Contractor (List Contractor,

 

4

- Other Federal employment

 

and/or name of person who can verify)

 

not Federal agency)

 

Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in your military duty locations or home ports.

Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.

Month/Year

Month/Year

 

Code

Employer/Verifier Name/Military Duty Location

 

Your Position Title/Military Rank

 

 

#1

To

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s/Verifier’s Street Address

 

 

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

Street Address of Job Location (if different than Employer’s Address)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

PREVIOUS

 

To

 

 

 

 

 

 

 

 

 

 

PERIODS

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

OF

 

To

 

 

 

 

 

 

 

 

 

 

ACTIVITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Block #1)

Month/Year

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

 

Code

Employer/Verifier Name/Military Duty Location

 

Your Position Title/Military Rank

 

 

#2

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s/Verifier’s Street Address

 

 

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Street Address of Job Location (if different than Employer’s Address)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

PREVIOUS

 

To

 

 

 

 

 

 

 

 

 

 

PERIODS

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

OF

 

To

 

 

 

 

 

 

 

 

 

 

ACTIVITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Block #2)

Month/Year

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

 

Code

Employer/Verifier Name/Military Duty Location

 

Your Position Title/Military Rank

 

 

#3

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s/Verifier’s Street Address

 

 

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Street Address of Job Location (if different than Employer’s Address)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

PREVIOUS

 

To

 

 

 

 

 

 

 

 

 

 

PERIODS

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

OF

 

To

 

 

 

 

 

 

 

 

 

 

ACTIVITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Block #3)

Month/Year

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 3

YOUR EMPLOYMENT ACTIVITIES (CONTINUED)

 

Month/Year Month/Year

Code Employer/Verifier Name/Military Duty Location

Your Position Title/Military Rank

#4

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s/Verifier’s Street Address

 

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

Street Address of Job Location (if different than Employer’s Address)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

PREVIOUS

 

 

To

 

 

 

 

 

 

 

 

 

PERIODS

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

OF

 

 

To

 

 

 

 

 

 

 

 

 

ACTIVITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Block #4)

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

 

Code

Employer/Verifier Name/Military Duty Location

 

Your Position Title/Military Rank

 

#5

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s/Verifier’s Street Address

 

 

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Street Address of Job Location (if different than Employer’s Address)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

PREVIOUS

 

 

To

 

 

 

 

 

 

 

 

 

PERIODS

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

OF

 

 

To

 

 

 

 

 

 

 

 

 

ACTIVITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Block #5)

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

Month/Year

Month/Year

 

Code

Employer/Verifier Name/Military Duty Location

 

Your Position Title/Military Rank

 

#6

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s/Verifier’s Street Address

 

 

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Street Address of Job Location (if different than Employer’s Address)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Supervisor’s Name & Street Address (if different than Job Location)

City (Country)

 

State

ZIP Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

PREVIOUS

 

 

To

 

 

 

 

 

 

 

 

 

PERIODS

 

 

 

 

 

 

 

 

 

 

 

 

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

OF

 

 

To

 

 

 

 

 

 

 

 

 

ACTIVITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Block #6)

Month/Year

 

 

Month/Year

Position Title

 

Supervisor

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

11PEOPLE WHO KNOW YOU WELL

List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose combined association with you covers as well as possible the last 5 years. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is listed elsewhere on this form.

Name

Dates Known

 

Telephone Number

 

 

 

#1

Month/Year

Month/Year

 

Day

(

)

 

 

 

To

 

 

Night

 

 

 

 

 

 

 

 

 

 

Home or Work Address

 

 

City (Country)

 

 

State

ZIP Code

 

 

 

 

 

 

 

Name

Dates Known

 

Telephone Number

 

 

 

#2

Month/Year

Month/Year

 

Day

(

)

 

 

 

To

 

 

Night

 

 

 

 

 

 

 

 

 

 

Home or Work Address

 

 

City (Country)

 

 

State

ZIP Code

 

 

 

 

 

 

 

Name

Dates Known

 

Telephone Number

 

 

 

#3

Month/Year

Month/Year

 

Day

(

)

 

 

 

To

 

 

Night

 

 

 

 

 

 

 

 

 

 

Home or Work Address

 

 

City (Country)

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 4

12 YOUR SELECTIVE SERVICE RECORD

Yes

No

aAre you a male born after December 31, 1959? If "No," go to 13. If "Yes," go to b.

bHave you registered with the Selective Service System? If "Yes," provide your registration number. If "No," show the reason for your legal exemption below.

 

 

 

Registration Number

 

Legal Exemption Explanation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR MILITARY HISTORY

 

 

Yes

No

 

13

 

 

aHave you served in the United States military?

bHave you served in the United States Merchant Marine?

List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service (#1) and work backward. If you had a break in service, each separate period should be listed.

Code. Use one of the codes listed below to identify your branch of service:

1 - Air Force

2 - Army

3 - Navy

4 - Marine Corps

5 - Coast Guard

6 - Merchant Marine

7 - National Guard

O/E. Mark "O" block for Officer or "E" block for Enlisted.

Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an "X"; use the two-letter code for the state to mark the block.

Country. If your service was with other than the U.S. Armed Forces, identify the country for which you served.

 

 

 

Month/Year Month/Year

Code

Service/Certificate #

O

E

 

Status

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

Active

Inactive

National

 

 

 

 

 

 

 

 

 

 

 

 

Active

Guard

 

 

 

 

 

 

 

 

 

 

 

 

Reserve

Reserve

 

 

 

 

 

 

To

 

 

 

 

 

(State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

14

ILLEGAL DRUGS

 

 

 

 

 

 

 

 

 

Yes

No

In the last year, have you used, possessed, supplied, or manufactured illegal drugs? When used without a prescription, illegal drugs include marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.). (NOTE: Neither your truthful response nor information derived from your response will be used as evidence against you in any subsequent criminal proceeding.)

If you answered "Yes," provide information relating to the types of substance(s), the nature of the activity, and any other details relating to your involvement with illegal drugs. Include any treatment or counseling received.

Month/Year Month/Year

To

To

To

Type of Substance

Explanation

Continuation Space

Use the continuation sheet(s) (SF86A) for additional answers to items 8, 9, and 10. Use the space below to continue answers to all other items and any information you would like to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your name and Social Security number. Before each answer, identify the number of the item.

After completing this form 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 sign and date the release on Page 6.

Certification That My Answers Are True

My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See section 1001 of title 18, United States Code).

Signature (Sign in ink)

Date

Enter your Social Security Number before going to the next page

Page 5

Standard Form 85

Form Approved

Revised December 2013

OMB No. 3206-0261

U.S. Office of Personnel Management

 

5 CFR Parts 731 and 736

 

QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date it in ink.

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 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 to include publically available electronic information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record information.

I understand that, for some sources of information, a separate specific release will be needed, and I may be contacted for such a release at a later date.

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 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 85, and that it may be disclosed by the Government only as authorized by law.

Photocopies of this authorization with my signature are valid. This authorization is valid for two (2) years from the date signed.

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

Home telephone number

 

 

 

 

 

 

PAGE 6