SF85P QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS

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

Page 1

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.

Purpose of this Form

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.

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.

Your Personal Interview

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.

The Investigative Process

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.

Authority to Request this Information

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.

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

Page 2

Instructions for Completing this Form

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.

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.

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.

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.

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.

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

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:

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.

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.

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.

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.

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.

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.

To disclose information to contractors, grantees, or volunteers performing

or working on a contract, service, grant, cooperative agreement, or job for

the Federal Government.

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.

To provide criminal history record information to the FBI, to help ensure

the accuracy and completeness of FBI and OPM records.

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.

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

Page 3

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.

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.

To disclose information to the National Archives and Records

Administration for use in records management inspections.

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:

OPM, or any component thereof; or

Any employee of OPM in his or her official capacity; or

Any employee of OPM in his or her individual capacity where

the Department of Justice or OPM has agreed to represent the

employee; or

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.

(1)

(2)

(3)

(4)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

aa.

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.

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

Page 4

Alabama AL

Alaska AK

Arizona AZ

Arkansas AR

California CA

Colorado CO

Connecticut CT

Delaware DE

District of Columbia DC

Florida FL

Georgia GA

Hawaii HI

Idaho ID

Illinois IL

Indiana IN

Iowa IA

Kansas KS

Kentucky KY

Louisiana LA

Maine ME

Maryland MD

Massachusetts MA

Michigan MI

Minnesota MN

Mississippi MS

Missouri MO

Montana MT

Nebraska NE

Nevada NV

New Hampshire NH

New Jersey NJ

New Mexico NM

New York NY

North Carolina NC

North Dakota ND

Ohio OH

Oklahoma OK

Oregon OR

Pennsylvania PA

Rhode Island RI

South Carolina SC

South Dakota SD

Tennessee TN

Texas TX

Utah UT

Vermont VT

Virginia VA

Washington WA

West Virginia WV

Wisconsin WI

Wyoming WY

American Samoa AS

Baker Island FQ

Guam GU

Howland Island HQ

Jarvis Island DQ

Johnson Atoll JQ

Kingman Reef KQ

Marshall Islands MH

Micronesia, Federated

States

Midway Islands MQ

Navassa Island BQ

Northern Mariana Islands MP

Palau PW

Palmyra Atoll LQ

Puerto Rico PR

Virgin Islands, United

States

Wake Island WQ

APO/FPO America AA

APO/FPO Europe AE

APO/FPO Pacific AP

LOCATION CODES

V Applicant affiliation

None

J SON

(Submitting Office Number)

Initial

Reinvestigation

S Investigative requirement

Investigating agency user only

Codes: (FIPC CODES)

Case Number:

P Obligating document number Q BETC

R Accounting data and/or Agency case number

T Requesting Official - Name

Title Signature

Title

Telephone number

(Include Ext.)

FED CIV

CON

Other

Other address/Web address of e-OPF

Zip Code

A Type of investigation

C Risk level E Nature of action code

G Geographic location

H Position code I Position title

K Location of Official Personnel Folder

U Secondary Requesting Official - Name

B Extra coverage/Advanced results

NPRC

At SON

e-OPF

Other

L SOI (Security Office Identifier) M Location of Security Folder

None

NPI

At SOI

Other

Email address

Email address Telephone number (Include Ext.) Date (Month/Day/Year)

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.

Zip Code

MIL

N IPAC

O TAS

AGENCY USE BLOCK "AUB"

W Deployment/PCS (if imminent)

Point of contact at location Address/Unit/Duty location (Include City or Post Name)

Commercial and Government Entity (CAGE) Code

Contract Number

F Date of action (Month/Day/Year)

Agency Special Instructions for the Investigative Service Provider.

Reason(s) for temporary duty assignment or PCSFrom (Month/Day/Year)

Telephone number (Include Ext.)

Estimated

Permanent Relocation

Est. To

(Month/Day/Year)

e-OPF

Other address/Web address of e-OPF

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

Page 5

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

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

Service.

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

YES NO

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 4 - Social Security Number

Section 3 - Place of Birth

Provide your place of birth.

City

County

Country

(Required)

State

Not applicable

Provide your U.S. Social Security Number.

Section 2 - Date of Birth

Est.

Section 5 - Other Names Used

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.

Have you used any other names?

Provide your date of

birth. (Month/Day/Year)

Middle nameFirst name

Last name

Provide the reason(s) why the name changed

Maiden name?

NOYES

Suffix

Est.

Present

Provide other name used

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

Middle nameFirst name

Last name

Provide the reason(s) why the name changed

Maiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

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

Middle nameFirst name

Last name

Provide the reason(s) why the name changed

Maiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

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

Middle nameFirst name

Last name

Provide the reason(s) why the name changed

Maiden name?

NOYES

Suffix

Est. Est.

Present

Provide other name used

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

Sex

Section 6 - Your Identifying Information

Provide your identifying information.

(inches)(feet)

Weight (in pounds) Hair color Eye color

Female

Male

Height

Enter your Social Security Number before going to the next page

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

Page 6

Section 7 - Your Contact Information

Home e-mail address Work e-mail address

Home telephone number

Extension

International or DSN phone number

Work telephone number

Extension

International or DSN phone number

Mobile/Cell telephone number

Extension

International or DSN phone number

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

background investigation.

Day

Night

Both

Day

Night

Both

Day

Night

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.

Passport number

Click HERE for U.S. State Department passport help

http://travel.state.gov/passport

Est.

Provide the name in which passport was first issued.

Middle name

Last name

First name

Suffix

Est.

(Month/Day/Year)(Month/Day/Year)

Issue date Expiration date

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 naturalized U.S. citizen. (Complete 9.2)

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

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

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

Provide the name in which document was issued.

Middle name

Last name

First name

Suffix

Provide the name in which the certificate was issued.

Middle name

Last name

First name

Suffix

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

YES NO (If NO, proceed to Section 10)

9.1 Complete 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.

Est.

Provide your citizenship certificate number.

Est.

Provide type of documentation of U.S. citizen born abroad.

FS 240 DS 1350 FS 545 Other (Provide explanation)

Provide the name of the base.

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

Country

State

City

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

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

Enter your Social Security Number before going to the next page

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

Page 7

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

State

City

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

Middle name

Last name

First name

Suffix

Street

Zip Code

Est.

Provide your Certificate of Naturalization number (N550 or N570).

(Provide explanation)

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

Est.

Provide your residence status.

Est.

Provide your alien registration

number (I-551, I-766)

Provide the name in which the document was issued.

Middle name

Last name

First name

Suffix

Provide document number.

Est.

Provide the basis of naturalization.

Other

Based on my own individual naturalization application

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 the name of the court that issued the

Certificate of Naturalization.

Section 9 - Citizenship - (Continued)

(Month/Day/Year)

Est.

State

City

Provide country(ies) of prior citizenship.

#1 Country

Provide the location of entry into the U.S.

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

Provide your U.S. alien registration number on Certificate of

Naturalization - utilize USCIS, CIS, or INS registration, I-551, I-766.

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

YES

#2 Country

Provide your place of entry in the U.S.

State

City

Provide your country(ies) of citizenship.

#1 Country

#2 Country

Provide your alien registration number (on Certificate of

Citizenship — utilize USCIS, CIS or INS registration number)

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

Provide your Permanent Resident Card

number (I-551)

Provide your Certificate of Citizenship

number (N560 or N561)

Provide the name in which the document was issued.

Middle name

Last name

First name

Suffix

(Provide explanation)

Provide the basis of derived citizenship.

Other

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

Est.

(Month/Day/Year)

Est.

(Month/Day/Year)

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

Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)

Provide the date document was issued

Provide the date of entry into the U.S.

(Month/Day/Year)

Provide document expiration

date (I-766 ONLY)

Provide the date document was issued Provide document expiration date.

Enter your Social Security Number before going to the next page

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

Page 8

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.)

Est.

Present

Est.

Do you currently hold citizenship with this country?

NOYES

Provide explanation:

Entry #2

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

NO (If NO, proceed to Section 11)YES

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.

(Month/Day/Year)

Est.

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

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

City Country

Last name

First name

Middle name

Suffix

Provide the passport (or identity card) number.

(Month/Day/Year)

Est.

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

NOYES

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)

Est. Est. Present

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

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

Provide the passport (or identity card) expiration date.

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.)

Est.

Present

Est.

Do you currently hold citizenship with this country?

NOYES

Provide explanation:

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

Enter your Social Security Number before going to the next page

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

Page 9

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.

(Month/Day/Year)

Est.

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

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

City Country

Last name

First name

Middle name

Suffix

Provide the passport (or identity card) number.

(Month/Day/Year)

Est.

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

NOYES

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)

Est. Est. Present

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

Provide the passport (or identity card) expiration date.

Enter your Social Security Number before going to the next page

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

Page 10

Section 11 - Where You Have Lived

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.

Entry #1

Est.

Present

Est.

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

Evening telephone number

Extension

International or DSN phone number

I don't know

Daytime telephone number

Extension

Cell/mobile telephone number

Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

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

Middle name

Last name

First name

Suffix

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

Neighbor Friend Landlord Business associate Other

(Provide explanation)

Street

City

State

Country

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.)

Zip Code

Provide e-mail address for this person.

I don't know

Enter residence information.

Est.

Provide date of last contact.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Zip Code

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.)

(a)

Address

APO or FPO

APO/FPO State Code Zip Code

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

YES

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

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 11

Section 11 - Where You Have Lived - (Continued)

Entry #2

Enter residence information.

Est.

Present

Est.

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

Evening telephone number

Extension

International or DSN phone number

I don't know

Daytime telephone number

Extension

Cell/mobile telephone number

Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

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

Middle name

Last name

First name

Suffix

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

Neighbor Friend Landlord Business associate Other

(Provide explanation)

Street

City

State

Country

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.)

Zip Code

Provide e-mail address for this person.

I don't know

Est.

Provide date of last contact.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Zip Code

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.)

(a)

Address

APO or FPO

APO/FPO State Code Zip Code

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

YES

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

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 12

Section 11 - Where You Have Lived - (Continued)

Entry #3

Enter residence information.

Est.

Present

Est.

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

Evening telephone number

Extension

International or DSN phone number

I don't know

Daytime telephone number

Extension

Cell/mobile telephone number

Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

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

Middle name

Last name

First name

Suffix

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

Neighbor Friend Landlord Business associate Other

(Provide explanation)

Street

City

State

Country

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.)

Zip Code

Provide e-mail address for this person.

I don't know

Est.

Provide date of last contact.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Zip Code

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.)

(a)

Address

APO or FPO

APO/FPO State Code Zip Code

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

YES

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

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 13

Section 11 - Where You Have Lived - (Continued)

Enter residence information.

Entry #4

Est.

Present

Est.

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

Evening telephone number

Extension

International or DSN phone number

I don't know

Daytime telephone number

Extension

Cell/mobile telephone number

Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

Owned by you

Military housing

Rented or leased by you

Other

Is/was this residence:

(Provide explanation)

Country

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

Middle name

Last name

First name

Suffix

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

Neighbor Friend Landlord Business associate Other

(Provide explanation)

Street

City

State

Country

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.)

Zip Code

Provide e-mail address for this person.

I don't know

Est.

Provide date of last contact.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Zip Code

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.)

(a)

Address

APO or FPO

APO/FPO State Code Zip Code

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

YES

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

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 14

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

Entry #1

Section 12 - Where You Went to School

(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)

Provide the dates of attendance.

Est.

Present

Est.

High School

Vocational/Technical/Trade School

College/University/Military College

Correspondence/Distance/Extension/Online School

Select the most appropriate below to describe your school.

YES NO

Street

City

State

Country

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.)

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.)

Zip Code

Did you receive a degree/diploma?

Provide the name of the school.

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.

Last name

First name

I don't know

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide telephone number for this person.

I don't know

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

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

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

Other degree/diploma

Date awarded

(Month/Year)

Est.

Provide email address for this person.

(Month/Year) (Month/Year)

Day Night

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

Entry #2

From Date To Date

Provide the dates of attendance.

Est.

Present

Est.

High School

Vocational/Technical/Trade School

College/University/Military College

Correspondence/Distance/Extension/Online School

Select the most appropriate below to describe your school.

Street

City

State

Country

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.)

Zip Code

Provide the name of the school.

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.

Last name

First name

I don't know

(Month/Year) (Month/Year)

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

From Date To Date

Enter your Social Security Number before going to the next page

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

Page 15

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

Entry #2 (Continued)

Entry #3

Provide the dates of attendance. Select the most appropriate below to describe your school.

YES NO

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.)

Did you receive a degree/diploma?

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide telephone number for this person.

I don't know

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

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

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

Other degree/diploma

Date awarded

(Month/Year)

Est.

Provide email address for this person.

Day Night

Est.

Present

Est.

High School

Vocational/Technical/Trade School

College/University/Military College

Correspondence/Distance/Extension/Online School

YES NO

Street

City

State

Country

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.)

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.)

Zip Code

Did you receive a degree/diploma?

Provide the name of the school.

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.

Last name

First name

I don't know

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide telephone number for this person.

I don't know

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

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

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

Other degree/diploma

Date awarded

(Month/Year)

Est.

Provide email address for this person.

(Month/Year) (Month/Year)

Day Night

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

From Date To Date

Enter your Social Security Number before going to the next page

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

Page 16

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

Entry #4

Provide the dates of attendance. Select the most appropriate below to describe your school.

Est.

Present

Est.

High School

Vocational/Technical/Trade School

College/University/Military College

Correspondence/Distance/Extension/Online School

YES NO

Street

City

State

Country

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.)

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.)

Zip Code

Did you receive a degree/diploma?

Provide the name of the school.

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.

Last name

First name

I don't know

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide telephone number for this person.

I don't know

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

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

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

Other degree/diploma

Date awarded

(Month/Year)

Est.

Provide email address for this person.

(Month/Year) (Month/Year)

Day Night

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

From Date To Date

Enter your Social Security Number before going to the next page

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

Page 17

Provide the name of your supervisor.

Provide the rank/position title of your supervisor.

Provide supervisor's telephone number.

Extension

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

Country

Zip Code

NightDay

International or DSN phone number

Street

City

State

Country

Provide address of duty station.

(

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

Zip Code

Section 13A - Employment Activities

Telephone number

Extension

International or DSN phone number

Day Night

Both

Provide the email address of your supervisor.

I don't know

Entry #1

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

Est.

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

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

Est.

Present

Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Both

To Date

(Month/Year)

From Date

(Month/Year)

Street Address/Unit/Duty Location

City or Post Name

State

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Select your employment activity:

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

and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1,

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

13A.5 and 13A.6)

State Government (Non-Federal employment)

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

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

13A.6)

Unemployment (Complete 13A.4)

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

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)

Enter your Social Security Number before going to the next page

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

Page 18

Section 13A - Employment Activities - (Continued)

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).

Provide the name of your supervisor.

Provide the position title of your supervisor.

Street

City

State

Country

Provide the address of employer.

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

Zip Code

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

Country

Zip Code

Provide telephone number

Extension

International or DSN phone number

Day Night

Entry #1

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

(b)

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

Provide telephone number

Extension

International or DSN phone number

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

Country

Zip Code

Day Night

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

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employer.

Provide most recent position title.

Est.

Present

Est.

Not

Applicable

From date (Month/Year)

To date (Month/Year)

Position Title Supervisor

Est. Est.

Provide supervisor's telephone number.

Extension

NightDay

International or DSN phone number

Provide the email address of your supervisor.

I don't know

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 19

Section 13A - Employment Activities - (Continued)

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

Country

Zip Code

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

Is your physical work address different than your employment address?

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.)

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

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide the telephone number for this address.

Day Night

Street

City

State

Country

Provide address of this employment.

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

Zip Code

Provide telephone number.

Extension

International or DSN phone number

Day Night

Telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #1

(b)

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employment.

Provide most recent position title.

Est.

Present

Est.

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).

Street Address/Unit/Duty Location

City or Post Name

State

Country

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 20

Last name

First name

Provide the name of someone that can verify your unemployment activities

and means of support.

Est.

Present

Est.

Provide dates of unemployment.

Provide address of this verifier.

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

Street City

State

Country

Zip Code

Verifier telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

Section 13A - Employment Activities - (Continued)

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.

Left by mutual agreement following

notice of unsatisfactory performance

Left by mutual agreement following

charges or allegations of misconduct

Quit after being told you would be

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

Est.

Provide the date you left following charges or allegations

of misconduct.

(Month/Year)

Provide the date you quit after being told you would be

fired. (Month/Year)

Provide the date you left by mutual agreement following

a notice of unsatisfactory performance. (Month/Year)

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

Est.

Date:

(Month/Year)

Date: (Month/Year)

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

Est.

YES NO

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?

Entry #1Entry #1Entry #1

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

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.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

Does your unemployment verifier have an APO/FPO address?

(a)

(b)

YES

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.

To Date

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

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

YES

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

Enter your Social Security Number before going to the next page

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

Page 21

Section 13A - Employment Activities

Entry #2

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

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

Select your employment activity:

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

and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1,

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

13A.5 and 13A.6)

State Government (Non-Federal employment)

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

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

13A.6)

Unemployment (Complete 13A.4)

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

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)

Provide the name of your supervisor.

Provide the rank/position title of your supervisor.

Provide supervisor's telephone number.

Extension

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

Country

Zip Code

NightDay

International or DSN phone number

Street

City

State

Country

Provide address of duty station.

(

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

Zip Code

Telephone number

Extension

International or DSN phone number

Day Night

Both

Provide the email address of your supervisor.

I don't know

Est.

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Est.

Present

Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Both

To Date

(Month/Year)

From Date

(Month/Year)

Street Address/Unit/Duty Location

City or Post Name

State

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Enter your Social Security Number before going to the next page

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

Page 22

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.

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).

Provide the name of your supervisor.

Provide the position title of your supervisor.

Street

City

State

Country

Provide the address of employer.

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

Zip Code

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

Country

Zip Code

Provide telephone number

Extension

International or DSN phone number

Day Night

(b)

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

Provide telephone number

Extension

International or DSN phone number

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

Country

Zip Code

Day Night

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

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employer.

Provide most recent position title.

Est.

Present

Est.

Not

Applicable

From date (Month/Year)

To date (Month/Year)

Position Title Supervisor

Est. Est.

Provide supervisor's telephone number.

Extension

NightDay

International or DSN phone number

Provide the email address of your supervisor.

I don't know

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 23

Section 13A - Employment Activities - (Continued)

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

Country

Zip Code

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

Is your physical work address different than your employment address?

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.)

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

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide the telephone number for this address.

Day Night

Street

City

State

Country

Provide address of this employment.

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

Zip Code

Provide telephone number.

Extension

International or DSN phone number

Day Night

Telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #2

(b)

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employment.

Provide most recent position title.

Est.

Present

Est.

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).

Street Address/Unit/Duty Location

City or Post Name

State

Country

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 24

Section 13A - Employment Activities - (Continued)

Entry #2Entry #2Entry #2

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

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.

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.

Last name

First name

Provide the name of someone that can verify your unemployment activities

and means of support.

Est.

Present

Est.

Provide dates of unemployment.

Provide address of this verifier.

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

Street City

State

Country

Zip Code

Verifier telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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.

Left by mutual agreement following

notice of unsatisfactory performance

Left by mutual agreement following

charges or allegations of misconduct

Quit after being told you would be

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

Est.

Provide the date you left following charges or allegations

of misconduct.

(Month/Year)

Provide the date you quit after being told you would be

fired. (Month/Year)

Provide the date you left by mutual agreement following

a notice of unsatisfactory performance. (Month/Year)

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

Est.

Date:

(Month/Year)

Date: (Month/Year)

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

Est.

YES NO

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?

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

Does your unemployment verifier have an APO/FPO address?

(a)

(b)

YES

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

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

YES

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

Enter your Social Security Number before going to the next page

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

Page 25

Section 13A - Employment Activities

Entry #3

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

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

Select your employment activity:

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

and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1,

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

13A.5 and 13A.6)

State Government (Non-Federal employment)

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

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

13A.6)

Unemployment (Complete 13A.4)

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

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)

Provide the name of your supervisor.

Provide the rank/position title of your supervisor.

Provide supervisor's telephone number.

Extension

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

Country

Zip Code

NightDay

International or DSN phone number

Street

City

State

Country

Provide address of duty station. (

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

Zip Code

Telephone number

Extension

International or DSN phone number

Day Night

Both

Provide the email address of your supervisor.

I don't know

Est.

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Est.

Present

Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Both

To Date

(Month/Year)

From Date

(Month/Year)

Street Address/Unit/Duty Location

City or Post Name

State

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Enter your Social Security Number before going to the next page

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

Page 26

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.

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).

Provide the name of your supervisor.

Provide the position title of your supervisor.

Street

City

State

Country

Provide the address of employer.

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

Zip Code

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

Country

Zip Code

Provide telephone number

Extension

International or DSN phone number

Day Night

(b)

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

Provide telephone number

Extension

International or DSN phone number

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

Country

Zip Code

Day Night

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

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employer.

Provide most recent position title.

Est.

Present

Est.

Not

Applicable

From date (Month/Year)

To date (Month/Year)

Position Title Supervisor

Est. Est.

Provide supervisor's telephone number.

Extension

NightDay

International or DSN phone number

Provide the email address of your supervisor.

I don't know

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 27

Section 13A - Employment Activities - (Continued)

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

Country

Zip Code

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

Is your physical work address different than your employment address?

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.)

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

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide the telephone number for this address.

Day Night

Street

City

State

Country

Provide address of this employment.

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

Zip Code

Provide telephone number.

Extension

International or DSN phone number

Day Night

Telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #3

(b)

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employment.

Provide most recent position title.

Est.

Present

Est.

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).

Street Address/Unit/Duty Location

City or Post Name

State

Country

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 28

Section 13A - Employment Activities - (Continued)

Entry #3Entry #3Entry #3

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

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.

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.

Last name

First name

Provide the name of someone that can verify your unemployment activities

and means of support.

Est.

Present

Est.

Provide dates of unemployment.

Provide address of this verifier.

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

Street City

State

Country

Zip Code

Verifier telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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.

Left by mutual agreement following

notice of unsatisfactory performance

Left by mutual agreement following

charges or allegations of misconduct

Quit after being told you would be

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

Est.

Provide the date you left following charges or allegations

of misconduct.

(Month/Year)

Provide the date you quit after being told you would be

fired. (Month/Year)

Provide the date you left by mutual agreement following

a notice of unsatisfactory performance. (Month/Year)

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

Est.

Date:

(Month/Year)

Date: (Month/Year)

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

Est.

YES NO

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?

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

Does your unemployment verifier have an APO/FPO address?

(a)

(b)

YES

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

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

YES

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

Enter your Social Security Number before going to the next page

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

Page 29

Section 13A - Employment Activities

Entry #4

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

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

Select your employment activity:

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

and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1,

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2,

13A.5 and 13A.6)

State Government (Non-Federal employment)

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

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

13A.6)

Unemployment (Complete 13A.4)

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

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)

Provide the name of your supervisor.

Provide the rank/position title of your supervisor.

Provide supervisor's telephone number.

Extension

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

Country

Zip Code

NightDay

International or DSN phone number

Street

City

State

Country

Provide address of duty station.

(

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

Zip Code

Telephone number

Extension

International or DSN phone number

Day Night

Both

Provide the email address of your supervisor.

I don't know

Est.

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Est.

Present

Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Both

To Date

(Month/Year)

From Date

(Month/Year)

Street Address/Unit/Duty Location

City or Post Name

State

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

Enter your Social Security Number before going to the next page

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

Page 30

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.

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).

Provide the name of your supervisor.

Provide the position title of your supervisor.

Street

City

State

Country

Provide the address of employer.

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

Zip Code

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

Country

Zip Code

Provide telephone number

Extension

International or DSN phone number

Day Night

(b)

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

Provide telephone number

Extension

International or DSN phone number

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

Country

Zip Code

Day Night

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

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employer.

Provide most recent position title.

Est.

Present

Est.

Not

Applicable

From date (Month/Year)

To date (Month/Year)

Position Title Supervisor

Est. Est.

Provide supervisor's telephone number.

Extension

NightDay

International or DSN phone number

Provide the email address of your supervisor.

I don't know

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 31

Section 13A - Employment Activities - (Continued)

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

Country

Zip Code

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

Is your physical work address different than your employment address?

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.)

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

Street

City

State

Country

Zip Code

Telephone number

Extension

International or DSN phone number

Provide the telephone number for this address.

Day Night

Street

City

State

Country

Provide address of this employment.

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

Zip Code

Provide telephone number.

Extension

International or DSN phone number

Day Night

Telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #4

(b)

(a)

Provide dates of employment. Select the employment status for

this position:

Part-time

Full-time

Provide the name of your employment.

Provide most recent position title.

Est.

Present

Est.

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).

Street Address/Unit/Duty Location

City or Post Name

State

Country

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(b.1)

(b.2)

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

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

(a)

(b)

YES

To Date

(Month/Year)

From Date

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 32

Section 13A - Employment Activities - (Continued)

Entry #4Entry #4Entry #4

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

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.

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.

Last name

First name

Provide the name of someone that can verify your unemployment activities

and means of support.

Est.

Present

Est.

Provide dates of unemployment.

Provide address of this verifier.

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

Street City

State

Country

Zip Code

Verifier telephone number

Extension

International or DSN phone number

Day Night

Provide the telephone number for this person.

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.

Left by mutual agreement following

notice of unsatisfactory performance

Left by mutual agreement following

charges or allegations of misconduct

Quit after being told you would be

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

Est.

Provide the date you left following charges or allegations

of misconduct.

(Month/Year)

Provide the date you quit after being told you would be

fired. (Month/Year)

Provide the date you left by mutual agreement following

a notice of unsatisfactory performance. (Month/Year)

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

Est.

Date:

(Month/Year)

Date: (Month/Year)

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

Est.

YES NO

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?

Street Address/Unit/Duty Location

City or Post Name

State

Country

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).

Address

APO or FPO

APO/FPO State Code Zip Code

Zip Code

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.)

Does your unemployment verifier have an APO/FPO address?

(a)

(b)

YES

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

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

YES

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

Enter your Social Security Number before going to the next page

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

Page 33

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.

From Date

(Month/Year)

Est.

To Date

(Month/Year)

Present

Est.

Provide the name of the federal agency for

which you are/were employed.

Provide your position title.

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.

From Date

(Month/Year)

Est.

To Date

(Month/Year)

Est.

Present

Provide your position title.

Provide the name of the federal agency for

which you are/were employed.

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.

From Date

(Month/Year)

Est.

To Date

(Month/Year)

Present

Est.

Provide the name of the federal agency for

which you are/were employed.

Provide your position title.

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.

From Date

(Month/Year)

Est.

To Date

(Month/Year)

Present

Est.

Provide the name of the federal agency for

which you are/were employed.

Provide your position title.

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?

NO (If NO, proceed to Section 14)

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

Section 14 - Selective Service Record

Were you born a male after December 31, 1959?

Yes

I don't know

Provide registration number:

Provide explanation:

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

registration number for persons who have registered. Note: Selective

Service Number is not your Social Security Number.

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

YES NO (If NO, proceed to Section 15)

Enter your Social Security Number before going to the next page

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

Page 34

Section 15 - Military History

YES NO (If NO, proceed to 15.2)

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

Army

Army National

Guard

Navy

Air Force

Air National

Guard

Marine Corps

Coast Guard

Provide the branch of service you served in.

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

State of service, if

National Guard

Enlisted

Not Applicable

Officer

Officer or enlisted

Provide your dates of service.

Est.

Present

Est.

From Date

(Month/Year)

Provide the date of

discharge listed

(Month/Year)

To Date

(Month/Year)

Provide your service number.

YES NO

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

Provide the type of discharge you received:

Honorable

Dishonorable

Bad Conduct

Other (provide type)

Under Other than

Honorable Conditions

General

Est.

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

Active Duty

Active Reserve

Inactive Reserve

Provide your status

Entry #1

Entry #2

Army

Army National

Guard

Navy

Air Force

Air National

Guard

Marine Corps

Coast Guard

Provide the branch of service you served in. State of service, if

National Guard

Enlisted

Not Applicable

Officer

Officer or enlisted

Provide your dates of service.

Est.

Present

Est.

From Date

(Month/Year)

Provide the date of

discharge listed

(Month/Year)

To Date

(Month/Year)

Provide your service number.

YES NO

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

Provide the type of discharge you received:

Honorable

Dishonorable

Bad Conduct

Other (provide type)

Under Other than

Honorable Conditions

General

Est.

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

Active Duty

Active Reserve

Inactive Reserve

Provide your status

Enter your Social Security Number before going to the next page

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

Page 35

YES NO (If NO proceed to 15.2)

Section 15 - Military History - (Continued)

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?

Est.

Entry #1

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

offense(s) for which you were charged.

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

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

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

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

and state or country if overseas).

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

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

imprisonment, etc.

Est.

Entry #2

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

offense(s) for which you were charged.

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

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

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

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

and state or country if overseas).

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

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

imprisonment, 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.

15.1(b)

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

Enter your Social Security Number before going to the next page

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

Page 36

Section 15 - Military History - (Continued)

YES NO (If NO, proceed to Section 16)

Have you 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?

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

Intelligence Service

Diplomatic Service

Security Forces

Militia

Other Defense Forces,

Other Government Agency,

Entry #2

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

Provide division/department/office in which you served.

Provide your highest position/rank held.Provide the name of the country.

Provide the name of the foreign organization.

Provide your period of service.

Est.

Present

From Date

(Month/Year)

To Date (Month/Year)

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

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.

Provide your period of service.

Est.

Present

From Date

(Month/Year)

To Date (Month/Year)

Provide the name of the foreign organization.

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

15.2

Entry #1

Specify

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

Intelligence Service

Diplomatic Service

Security Forces

Militia

Other Defense Forces,

Other Government Agency,

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

Specify

Enter your Social Security Number before going to the next page

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

Page 37

To Date (Month/Year)

From Date (Month/Year)

Night

Middle name

First name

Last name

Provide e-mail address for this person.

Suffix

Provide telephone number for

this person.

International or DSN

phone number

Extension

Est.

Provide dates known.

Present

Est.

Provide relationship to you. (Select all that apply)

City

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

State

Country

Zip Code

Provide mobile/cell telephone

number for this person.

I don't know

Schoolmate

Other (Provide explanation)

Provide rank/title

Friend

Neighbor

Not applicable

Provide full name.

I don't know

Work associate

Day

NightDay

International or DSN

phone number

Extension

I don't know

Section 16 - People Who Know You Well

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

To Date

(Month/Year)

From Date (Month/Year)

Night

Middle name

First name

Last name

Provide e-mail address for this person.

Suffix

Provide telephone number for

this person.

International or DSN

phone number

Extension

Est.

Provide dates known.

Present

Est.

Provide relationship to you. (Select all that apply)

City

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

State

Country

Zip Code

Provide mobile/cell telephone

number for this person.

I don't know

Schoolmate

Other (Provide explanation)

Provide rank/title

Friend

Neighbor

Not applicable

Provide full name.

I don't know

Work associate

Day

NightDay

International or DSN

phone number

Extension

I don't know

Entry #2

To Date

(Month/Year)

From Date (Month/Year)

Night

Middle name

First name

Last name

Provide e-mail address for this person.

Suffix

Provide telephone number for

this person.

International or DSN

phone number

Extension

Est.

Provide dates known.

Present

Est.

Provide relationship to you. (Select all that apply)

City

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

State

Country

Zip Code

Provide mobile/cell telephone

number for this person.

I don't know

Schoolmate

Other (Provide explanation)

Provide rank/title

Friend

Neighbor

Not applicable

Provide full name.

I don't know

Work associate

Day

NightDay

International or DSN

phone number

Extension

I don't know

Entry #3

Enter your Social Security Number before going to the next page

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

Page 38

Country #1

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Country #2

Provide country(ies) of citizenship.

Section 17 - Marital/Relationship Status

Divorced/Dissolved (Complete 17.2 and 17.3)

Separated (Complete 17.1 and 17.3)

Annulled (Complete 17.2 and 17.3)

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

recognized domestic partnership (Complete 17.1 and 17.3)

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

recognized domestic partnership (Complete 17.3)

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

Widowed (Complete 17.2 and 17.3)

Middle name SuffixLast name First name

Est.

Provide full name.

DS 1350

U.S. Passport (current or most recent)

Alien Registration

FS 240 or 545

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

Other (Provide explanation)

Provide U.S. Social Security Number.

Provide document number.

Not applicable

Provide place of birth.

City

County

State

Country

(required)

17.1 Complete 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.

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).

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

None (Provide explanation)

U.S. Certificate of Naturalization U.S. Certificate of

Citizenship

(Month/Day/Year)

Est.

To (Month/Year)

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

From (Month/Year)

Provide the date of birth.

(Month/Day/Year)

Provide date when you entered into your civil

marriage, civil union, or domestic partnership.

Maiden name?

Enter your Social Security Number before going to the next page

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

Page 39

YES

Street Address/Unit/Duty Location

City or Post Name

State

Country

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.)

Zip Code

Provide date of separation.

(Month/Day/Year)

Est.

Provide location. (

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

City

County

State

Country

Provide telephone number.

Extension

Provide email address.

Use my current telephone number

International or DSN phone number

Provide current address.

(

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

Street

City

State

Country

Zip Code

Are you separated?

City

State

Country

If legally separated, provide the location of the record.

(

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

Zip Code

Not Applicable

Day

Night

Section 17 - Marital/Relationship Status - (Continued)

17.1 Complete 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)

Use my current address

Address

APO or FPO

APO/FPO State Code Zip Code

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

YES

Enter your Social Security Number before going to the next page

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

Page 40

YES NO (If NO, complete (a)) I don't know

Est.

Provide the country(ies) of citizenship.

Country #1

Country #2

Middle name Suffix

Last name First name

Est.

Provide the full name.

Entry #1

Provide the place of birth.

City State

Country

(Required)

Zip Code

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

dissolved, annulled, or widowed.

Provide the location. (

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

City State

Country

Section 17 - Marital/Relationship Status - (Continued)

AnnulledWidowedDivorced/Dissolved

Provide the status.

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

Country

Zip Code

Is this person deceased?

Provide last known address of the person from whom you are divorced/dissolved or annulled. (

Provide City and Country if outside the

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

Street

City

State

Country

Zip Code

I don't know

(a)

Est.

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

Provide the date of birth.

(Month/Day/Year)

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

YES NO

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

Enter your Social Security Number before going to the next page

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

Page 41

Entry #2

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

divorced/dissolved, annulled, or widowed.

Section 17 - Marital/Relationship Status - (Continued)

YES NO (If NO, complete (a)) I don't know

Est.

Provide the country(ies) of citizenship.

Country #1

Country #2

Middle name Suffix

Last name First name

Est.

Provide the full name.

Provide the place of birth.

City State

Country

(Required)

Zip Code

Provide the location. (

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

City State

Country

AnnulledWidowedDivorced/Dissolved

Provide the status.

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

Country

Zip Code

Is this person deceased?

Provide last known address of the person from whom you are divorced/dissolved or annulled. (

Provide City and Country if outside the

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

Street

City

State

Country

Zip Code

I don't know

(a)

Est.

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

Provide the date of birth.

(Month/Day/Year)

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

YES NO

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

Enter your Social Security Number before going to the next page

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

Page 42

YES NO (If NO, proceed to Section 18)

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

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.

(Month/Day/Year)

17.3

Complete the following if you presently reside with a cohabitant.

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Country #1 Country #2

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

Entry #1

Middle name

Provide the cohabitant date of birth.

Suffix

Last name First name

Est.

Provide the cohabitant full name.

Provide the cohabitant place of birth.

City State

Country

(Required)

Section 17 - Marital/Relationship Status - (Continued)

Not applicable

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

name was used).

Middle nameFirst name

Last name

Suffix

Est.

Present

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Provide document number.

Not applicable

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

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

To (Month/Year)

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

From (Month/Year)

Provide date cohabitation began.

(Month/Day/Year)

Date

Maiden name?

DS 1350

U.S. Passport (current or most recent)

Alien Registration

FS 240 or 545

Other (Provide explanation)

None (Provide explanation)

U.S. Certificate of Naturalization U.S. Certificate of

Citizenship

Est.

Enter your Social Security Number before going to the next page

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

Page 43

YES NO (If NO, proceed to Section 18)

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

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.

17.3

Complete the following if you presently reside with a cohabitant.

Entry #2

Section 17 - Marital/Relationship Status - (Continued)

(Month/Day/Year)

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Country #1 Country #2

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

Middle name

Provide the cohabitant date of birth.

Suffix

Last name First name

Est.

Provide the cohabitant full name.

Provide the cohabitant place of birth.

City State

Country

(Required)

Not applicable

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

name was used).

Middle nameFirst name

Last name

Suffix

Est.

Present

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Provide document number.

Not applicable

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

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

To (Month/Year)

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

From (Month/Year)

Provide date cohabitation began.

(Month/Day/Year)

Date

Maiden name?

DS 1350

U.S. Passport (current or most recent)

Alien Registration

FS 240 or 545

Other (Provide explanation)

None (Provide explanation)

U.S. Certificate of Naturalization U.S. Certificate of

Citizenship

Est.

Enter your Social Security Number before going to the next page

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

Page 44

Has this relative used any other names?

NOYES

Not applicable

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

name, alias, or nickname).

City

State

Country

(Required)

Provide your relative's place of birth.

Middle nameLast name

Provide your relative's full name.

Suffix

First name

Suffix

Middle name

Last name

First name

If mother, provide your mother's maiden name.

Same as listed

18.1 Complete 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.

I don't know

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est.

Maiden name?

YES NO

Provide the reason(s) why the name changed.

Provide relative type.

Country #1

Country #2

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

Provide your relative's date of birth.

Est.

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

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.

Section 18 - Relatives

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #1

To (Month/Year)

From (Month/Year)

To (Month/Year)

From (Month/Year)

To (Month/Year)

From (Month/Year)

Date (Month/Year)

Present

Est.

Provide the reason(s) why the name changed.

To (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 45

Section 18 - Relatives - (Continued)

Provide your relative's current address. (

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

Provide your relative's APO/FPO address.

YES

I don't know

Is your relative deceased?

YES

NO (If NO, proceed to 18.2)

Zip Code

Does this relative have an APO/FPO address?

Address

APO or FPO

APO/FPO State Code

Street

City

State

Country

Zip Code

18.2 Complete 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.

Entry #1

Enter your Social Security Number before going to the next page

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

Page 46

Section 18 - Relatives - (Continued)

18.1 Complete 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.

Entry #2

City

State

Country

(Required)

Provide your relative's place of birth.

Middle nameLast name

Provide your relative's full name.

Suffix

First name

Provide relative type.

Country #1

Country #2

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

Provide your relative's date of birth.

Est.

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

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.

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #2

Date

(Month/Year)

Has this relative used any other names?

NOYES

Not applicable

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

name, alias, or nickname).

Suffix

Middle name

Last name

First name

If mother, provide your mother's maiden name.

Same as listed I don't know

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est.

Present

Est.

Maiden name?

YES NO

Provide the reason(s) why the name changed.

To (Month/Year)

From (Month/Year)

To (Month/Year)

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

From (Month/Year)

To (Month/Year)

From (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 47

Section 18 - Relatives - (Continued)

Is your relative deceased?

YES NO (If NO, proceed to 18.2)

18.2 Complete 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.

Entry #2

Provide your relative's current address. (

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

Provide your relative's APO/FPO address.

YES

I don't know

Zip Code

Does this relative have an APO/FPO address?

Address

APO or FPO

APO/FPO State Code

Street

City

State

Country

Zip Code

Enter your Social Security Number before going to the next page

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

Page 48

Section 18 - Relatives - (Continued)

18.1 Complete 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.

Entry #3

City

State

Country

(Required)

Provide your relative's place of birth.

Middle nameLast name

Provide your relative's full name.

Suffix

First name

Provide relative type.

Country #1

Country #2

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

Provide your relative's date of birth.

Est.

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

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.

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #3

Date

(Month/Year)

Has this relative used any other names?

NOYES

Not applicable

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

name, alias, or nickname).

Suffix

Middle name

Last name

First name

If mother, provide your mother's maiden name.

Same as listed I don't know

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est.

Present

Est.

Maiden name?

YES NO

Provide the reason(s) why the name changed.

To (Month/Year)

From (Month/Year)

To (Month/Year)

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

From (Month/Year)

To (Month/Year)

From (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 49

Section 18 - Relatives - (Continued)

Is your relative deceased?

YES NO (If NO, proceed to 18.2)

18.2 Complete 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.

Entry #3

Provide your relative's current address. (

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

Provide your relative's APO/FPO address.

YES

I don't know

Zip Code

Does this relative have an APO/FPO address?

Address

APO or FPO

APO/FPO State Code

Street

City

State

Country

Zip Code

Enter your Social Security Number before going to the next page

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

Page 50

Section 18 - Relatives - (Continued)

18.1 Complete 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.

Entry #4

City

State

Country

(Required)

Provide your relative's place of birth.

Middle nameLast name

Provide your relative's full name.

Suffix

First name

Provide relative type.

Country #1

Country #2

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

Provide your relative's date of birth.

Est.

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

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.

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #4

Date

(Month/Year)

Has this relative used any other names?

YES

Not applicable

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

name, alias, or nickname).

Suffix

Middle name

Last name

First name

If mother, provide your mother's maiden name.

Same as listed I don't know

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est.

Present

Est.

Maiden name?

YES NO

Provide the reason(s) why the name changed.

To (Month/Year)

From (Month/Year)

To (Month/Year)

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

From (Month/Year)

To (Month/Year)

From (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 51

Section 18 - Relatives - (Continued)

Is your relative deceased?

YES NO (If NO, proceed to 18.2)

18.2 Complete 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.

Entry #4

Provide your relative's current address. (

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

Provide your relative's APO/FPO address.

YES

I don't know

Zip Code

Does this relative have an APO/FPO address?

Address

APO or FPO

APO/FPO State Code

Street

City

State

Country

Zip Code

Enter your Social Security Number before going to the next page

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

Page 52

Section 18 - Relatives - (Continued)

18.1 Complete 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.

Entry #5

City

State

Country

(Required)

Provide your relative's place of birth.

Middle nameLast name

Provide your relative's full name.

Suffix

First name

Provide relative type.

Country #1

Country #2

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

Provide your relative's date of birth.

Est.

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

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.

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #5

Date

(Month/Year)

Has this relative used any other names?

NOYES

Not applicable

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

name, alias, or nickname).

Suffix

Middle name

Last name

First name

If mother, provide your mother's maiden name.

Same as listed I don't know

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est.

Present

Est.

Maiden name?

YES NO

Provide the reason(s) why the name changed.

To (Month/Year)

From (Month/Year)

To (Month/Year)

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

From (Month/Year)

To (Month/Year)

From (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 53

Section 18 - Relatives - (Continued)

Is your relative deceased?

18.2 Complete 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.

Entry #5

YES NO (If NO, proceed to 18.2)

Provide your relative's current address. (

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

Provide your relative's APO/FPO address.

YES

I don't know

Zip Code

Does this relative have an APO/FPO address?

Address

APO or FPO

APO/FPO State Code

Street

City

State

Country

Zip Code

Enter your Social Security Number before going to the next page

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

Page 54

Section 18 - Relatives - (Continued)

18.1 Complete 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.

Entry #6

City

State

Country

(Required)

Provide your relative's place of birth.

Middle nameLast name

Provide your relative's full name.

Suffix

First name

Provide relative type.

Country #1

Country #2

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

Provide your relative's date of birth.

Est.

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

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.

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #6

Date

(Month/Year)

Has this relative used any other names?

NOYES

Not applicable

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

name, alias, or nickname).

Suffix

Middle name

Last name

First name

If mother, provide your mother's maiden name.

Same as listed I don't know

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est. Est.

Present

Maiden name?

YES NO

Middle nameFirst name

Last name

Suffix

Est.

Present

Est.

Maiden name?

YES NO

Provide the reason(s) why the name changed.

To (Month/Year)

From (Month/Year)

To (Month/Year)

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

From (Month/Year)

To (Month/Year)

From (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 55

Section 18 - Relatives - (Continued)

Is your relative deceased?

18.2 Complete 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.

Entry #6

YES NO (If NO, proceed to 18.2)

Provide your relative's current address. (

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

Provide your relative's APO/FPO address.

YES

I don't know

Zip Code

Does this relative have an APO/FPO address?

Address

APO or FPO

APO/FPO State Code

Street

City

State

Country

Zip Code

Enter your Social Security Number before going to the next page

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

Page 56

NO (If NO, proceed to Section 20)YES

YES (If YES, proceed to Section 20) 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.

Section 19 - Foreign Countries You have Visited

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

Entry #1

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

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

Government business)?

Provide the dates of your travel to this country.

Est.

Present

Est.

If yes, provide explanation.

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?

If yes, provide explanation.

YES

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

If yes, provide explanation.

YES

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?

Provide the country visited.

Provide the total number of days involved in the visit.

1-5

6-10

11-20

21-30

More than 30

Many short trips

Visit family or friends

Trade shows, conferences, and seminarsEducation

TourismVolunteer activities

Business/Professional

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

Other

YES

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

Entry #2

Provide the dates of your travel to this country.

Est.

Present

Est.

If yes, provide explanation.

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?

If yes, provide explanation.

YES

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

If yes, provide explanation.

YES

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?

Provide the country visited.

Provide the total number of days involved in the visit.

1-5

6-10

11-20

21-30

More than 30

Many short trips

Visit family or friends

Trade shows, conferences, and seminarsEducation

TourismVolunteer activities

Business/Professional

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

Other

YES

(Month/Year)From (Month/Year)

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.

Enter your Social Security Number before going to the next page

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

Page 57

Section 19 - Foreign Countries You have Visited - Continued

Entry #3

Provide the dates of your travel to this country.

Est.

Present

Est.

If yes, provide explanation.

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?

If yes, provide explanation.

YES

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

If yes, provide explanation.

YES

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

Provide the country visited.

Provide the total number of days involved in the visit.

1-5

6-10

11-20

21-30

More than 30

Many short trips

Visit family or friends

Trade shows, conferences, and seminarsEducation

TourismVolunteer activities

Business/Professional

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

Other

YES

(Month/Year)From (Month/Year)

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 dates of your travel to this country.

Est.

Present

Est.

If yes, provide explanation.

YES

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?

If yes, provide explanation.

YES

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

If yes, provide explanation.

YES

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?

Provide the country visited.

Provide the total number of days involved in the visit.

1-5

6-10

11-20

21-30

More than 30

Many short trips

Visit family or friends

Trade shows, conferences, and seminarsEducation

TourismVolunteer activities

Business/Professional

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

Other

(Month/Year)From (Month/Year)

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.

Enter your Social Security Number before going to the next page

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

Page 58

20.1

YES NO (If NO, proceed to 20.2)

YES

NO (If NO, proceed to (c))

(a)

(b)

(c)

- 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?

Provide the name of the court.

(If YES, complete (c.1))

Entry #1

Section 20 - Police Record

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

pertains to the actions that are identified below.)

Entry #1

Est.

Provide a description of the specific nature of the offense.

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.

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

State

Country

Zip Code

Did this offense involve any of the following?

YES NO

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?

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

State

Country

Zip Code

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

City

State

Country

Zip Code

Provide explanation

Felony/misdemeanor Charge Outcome Date (Month/Year)

Est.

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.

County

(c.1)

(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 date of offense. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 59

(d)

YES (If YES, complete (d.1)) NO (If NO, complete (d.2))

(d.1)

(Month/Year) (Month/Year)

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

actually were incarcerated.

Present

Est.

Not Applicable

(Month/Year) (Month/Year)

(d.2)

Entry #1

Section 20 - Police Record - (Continued)

Were you sentenced as a result of this offense?

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?

NOYES

Est.

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

probation or parole.

Est.

Present

Est.

Not Applicable

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

YES NO

Provide explanation.

To Date From Date

Entry #1

Enter your Social Security Number before going to the next page

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

Page 60

Entry #2

Section 20 - Police Record - (Continued)

Entry #2

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?

YES

NO (If NO, proceed to (c))

(a)

(b)

(c)

Provide the name of the court.

(If YES, complete (c.1))

Est.

Provide a description of the specific nature of the offense.

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

State

Country

Zip Code

Did this offense involve any of the following?

YES NO

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?

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

State

Country

Zip Code

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

City

State

Country

Zip Code

Provide explanation

Felony/misdemeanor Charge Outcome Date (Month/Year)

Est.

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.

County

(c.1)

(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 date of offense. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 61

Entry #2

Section 20 - Police Record - (Continued)

(d)

YES (If YES, complete (d.1)) NO (If NO, complete (d.2))

(d.1)

(Month/Year) (Month/Year)

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

actually were incarcerated.

Present

Est.

Not Applicable

(Month/Year) (Month/Year)

(d.2)

Were you sentenced as a result of this offense?

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?

NOYES

Est.

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

probation or parole.

Est.

Present

Est.

Not Applicable

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

YES NO

Provide explanation.

To Date From Date

Entry #2

Enter your Social Security Number before going to the next page

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

Page 62

YES NO (If NO, proceed to 20.3)

20.2

(a)

(b)

YES NO

(b.1)

- 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?

(Month/Year)

Felony/misdemeanor Charge Outcome Date (Month/Year)

Est.

Section 20 - Police Record - (Continued)

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

Entry #1

Est.

Provide a description of the specific nature of the offense.

Did this offense involve any of the following?

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)

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.

Were you sentenced as a result of these charges?

YES (If YES, complete (b.1)) NO (If NO, complete (b.2))

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

actually were incarcerated.

Est.

Present

Est.

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

probation or parole.

Est.

Present

Est.

Not Applicable

(b.2)

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

YES NO

Provide explanation.

City

State

Country

Zip Code

County

To Date From Date

Provide the date of offense.

(Month/Year)

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?

Enter your Social Security Number before going to the next page

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

Page 63

Section 20 - Police Record - (Continued)

Entry #2

(a)

(b)

YES NO

(b.1)

(Month/Year)

Felony/misdemeanor Charge Outcome Date (Month/Year)

Est.

Provide a description of the specific nature of the offense.

Did this offense involve any of the following?

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)

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.

Were you sentenced as a result of these charges?

YES (If YES, complete (b.1)) NO (If NO, complete (b.2))

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

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?

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

actually were incarcerated.

Est.

Present

Est.

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

probation or parole.

Est.

Present

Est.

Not Applicable

(b.2)

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

YES NO

Provide explanation.

City

State

Country

Zip Code

County

To Date From Date

Provide the date of offense.

(Month/Year)

Enter your Social Security Number before going to the next page

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

Page 64

YES NO (If NO, proceed to Section 21)

20.3

Section 20 - Police Record - (Continued)

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

Entry #1

Est.

Provide explanation.

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

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

Country

Zip Code

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

Entry #2

Est.

Provide explanation.

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

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

Country

Zip Code

Entry #3

Est.

Provide explanation.

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

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

Country

Zip Code

Entry #4

Est.

Provide explanation.

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

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

Country

Zip Code

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

Enter your Social Security Number before going to the next page

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

Page 65

YES NO

21.1

YES NO

Entry #2

Provide the type of drug or controlled substance.

(Provide explanation)

Est. 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

a position directly and immediately affecting the public safety?

Provide an estimate of the month and

year of most recent use.

(Month/Year)

Provide an estimate of the month

and year of first use. (Month/Year)

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.

Section 21 - Illegal Use of Drugs and Drug Activity

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.

YES NO (If NO, proceed to 21.2)

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

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.

Est. 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

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.

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

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

Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)

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

Depressants (Such as barbiturates, methaqualone, tranquilizers, 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)

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

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

Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)

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

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

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)

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

Provide an estimate of the month and

year of most recent use.

(Month/Year)

Provide an estimate of the month

and year of first use. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 66

21.2

(Provide explanation)

Provide the nature and frequency of activity.

Est. Est.

Provide explanation.

(Provide explanation)

Provide explanation.

Entry #2

Provide the type of drug or controlled substance.

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

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance?

NOYES

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

YES

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

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

YES NO (If NO, proceed to 21.3)

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

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.

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

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance?

YES NO

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

YES

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

Provide the nature and frequency of activity.

Est. Est.

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

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

Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)

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

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

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)

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

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

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

Ketamine (Such as special K, jet, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.)

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

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

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)

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

Provide an estimate of the month and year

of most recent involvement.

(Month/Year)

Provide an estimate of the month and

year of first involvement. (Month/Year)

Provide an estimate of the month and year

of most recent involvement. (Month/Year)

Provide an estimate of the month and

year of first involvement. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 67

Present

(Month/Year) (Month/Year)

Est.

Present

(Month/Year) (Month/Year)

Est.

Entry #2

Provide the dates of involvement/use. 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.

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

21.3

YES NO (If NO, proceed to 21.4)

In the last seven (7) years, have you 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?

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 the dates of involvement/use. 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.

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

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

From Date

To Date

From Date

To Date

Enter your Social Security Number before going to the next page

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

Page 68

21.4

Present

(Month/Year) (Month/Year)

Est.

Present

(Month/Year) (Month/Year)

Est.

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

YES

NO (If NO, proceed to 21.5)

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

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 dates of involvement in the above. Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Provide the name of the prescription drug that you misused.

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

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance?

NOYES

Entry #2

Provide the dates of involvement in the above. Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Provide the name of the prescription drug that you misused.

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

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance?

NOYES

To Date From Date

Enter your Social Security Number before going to the next page

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

Page 69

21.5

(Month/Year) (Month/Year)

Present

Est.

Provide the dates of treatment.

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

YES NO (If NO, proceed to 21.6)

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?

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 medical professional

A mental health professional

A court official / judge

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

counseling or treatment by any of the above.

Provide explanation

Did you take action to receive counseling or treatment?

NO (If NO, complete (a))YES (If YES, complete (b))

Provide explanation.

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

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

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

Country

Zip Code

Last name

First name

Provide a telephone number for the

treatment provider.

Extension

International or DSN

phone number

Day Night

Provide the name of the treatment provider.

Did you successfully complete the treatment?

YES NO

(Provide explanation)

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

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

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

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)

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

To Date

From Date

Enter your Social Security Number before going to the next page

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

Page 70

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):

(Month/Year) (Month/Year)

Present

Est.

Provide the dates of treatment.

An employer, military commander, or employee assistance program

A medical professional

A mental health professional

A court official / judge

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

counseling or treatment by any of the above.

Provide explanation

Did you take action to receive counseling or treatment?

NO (If NO, complete (a))YES (If YES, complete (b))

Provide explanation.

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

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

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

Country

Zip Code

Last name

First name

Provide a telephone number for the

treatment provider.

Extension

International or DSN

phone number

Day Night

Provide the name of the treatment provider.

Did you successfully complete the treatment?

YES NO

(Provide explanation)

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

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

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

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Steroids (Such as the clear, juice, etc.)

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

To Date

From Date

Enter your Social Security Number before going to the next page

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

Page 71

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

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

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

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

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

Depressants (Such as barbiturates, methaqualone, tranquilizers, 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)

21.6

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

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

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

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

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

Depressants (Such as barbiturates, methaqualone, tranquilizers, 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)

Entry #2

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

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

Country

Zip Code

(Month/Year) (Month/Year)

Present

Est.

Provide the dates of treatment.

Provide a telephone number for the

treatment provider.

Extension

International or DSN phone

number

Day Night

Last name

First name

Provide the name of the treatment provider.

Did you successfully complete the treatment?

YES NO

(Provide explanation)

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

YES NO (If NO, proceed to Section 22)

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?

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.

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

Country

Zip Code

(Month/Year) (Month/Year)

Present

Est.

Provide the dates of treatment.

Provide a telephone number for the

treatment provider.

Extension

International or DSN phone

number

Day Night

Last name

First name

Provide the name of the treatment provider.

Did you successfully complete the treatment?

YES NO

(Provide explanation)

To Date

From Date To Date

From Date

Enter your Social Security Number before going to the next page

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

Page 72

22.1

Section 22 - Use of Alcohol

YES NO (If NO, proceed to 22.2)

In the last seven (7) years has your use of alcohol 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?

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.

Est.

Provide circumstances. Provide negative impact.

Provide dates of involvement or use.

Present

Est.

Entry #2

Provide the month/year when this negative impact occurred.

Est.

Provide circumstances. Provide negative impact.

Provide dates of involvement or use.

Present

Est.

Entry #3

Provide the month/year when this negative impact occurred.

Est.

Provide circumstances. Provide negative impact.

Provide dates of involvement or use.

Present

Est.

Entry #4

Provide the month/year when this negative impact occurred.

Est.

Provide circumstances. Provide negative impact.

Provide dates of involvement or use.

Present

Est.

From Date (Month/Year)

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

To Date (Month/Year)

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

From Date (Month/Year)

Provide an explanation of the circumstances and the negative impact.

Enter your Social Security Number before going to the next page

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

Page 73

International or DSN phone number

Day Night

Section 22 - Use of Alcohol - (Continued)

YES NO (If NO, proceed to 22.3)

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

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

Extension

Provide telephone number.

Did you take action to receive counseling or treatment?

NO (If NO, complete (a))YES (If YES, complete (b))

Provide explanation.

(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.

(b) You responded 'Yes' to having taken action to seek counseling or treatment.

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

Country

Zip Code

Provide the name of the individual counselor or treatment provider.

Did you successfully complete the treatment program?

YES NO

(Provide explanation)

22.2

Provide the dates of counseling or treatment.

Present

Est.

Entry #2

International or DSN phone number

Day Night

Extension

Provide telephone number.

Did you take action to receive counseling or treatment?

NO (If NO, complete (a))YES (If YES, complete (b))

Provide explanation.

(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.

(b) You responded 'Yes' to having taken action to seek counseling or treatment.

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

Country

Zip Code

Provide the name of the individual counselor or treatment provider.

Did you successfully complete the treatment program?

YES NO

(Provide explanation)

Provide the dates of counseling or treatment.

Present

Est.

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

Enter your Social Security Number before going to the next page

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

Page 74

22.3

Entry #2

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

Country

Zip Code

Provide telephone number.

Extension

International or DSN phone number

Day Night

Provide the name of the individual counselor or treatment provider.

Provide the dates of counseling or treatment.

Present

Est.

Did you successfully complete the treatment program?

YES NO

(Provide explanation)

Section 22 - Use of Alcohol - (Continued)

YES NO (If NO, proceed to 23)

In the last seven (7) years have you voluntarily sought counseling or treatment as a result of your use of alcohol?

Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment.

Entry #1

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

Country

Zip Code

Provide telephone number.

Extension

International or DSN phone number

Day Night

Provide the name of the individual counselor or treatment provider.

Provide the dates of counseling or treatment.

Present

Est.

Did you successfully complete the treatment program?

YES NO

(Provide explanation)

To Date (Month/Year)

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

From Date (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 75

(Provide name of government)

23.1

Est.

I don't know

Est.

I don't know

(Provide name of government)

Est.

I don't know

Est.

I don't know

Entry #2

Provide the investigating agency:

U.S. Department of Defense

U.S. Department of State

U.S. Office of Personnel Management

Federal Bureau of Investigation

U.S. Department of Treasury

U.S. Department of Homeland Security

Foreign government

I don't know

Other (Provide explanation)

Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

Provide the level of clearance eligibility/access granted:

None

Confidential

Secret

Top Secret

Sensitive Compartmented Information (SCI)

I don't know

Other

(Provide explanation)

Issued by foreign country

Section 23 - Investigations and Clearance Record

YES NO (If NO, proceed to 23.2)

Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you

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 State

U.S. Office of Personnel Management

Federal Bureau of Investigation

U.S. Department of Treasury

U.S. Department of Homeland Security

Foreign government

I don't know

Other (Provide explanation)

Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

Provide the level of clearance eligibility/access granted:

None

Confidential

Secret

Top Secret

Sensitive Compartmented Information (SCI)

I don't know

Other (Provide explanation)

Issued by foreign country

(Provide name of bureau)

Date the investigation was completed (Month/Year)

Provide the date clearance eligibility/access was granted. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 76

23.2

Entry #2

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

Provide the name of the government

agency taking debarment action.

Est.

Provide the name of the government

agency taking debarment action.

Est.

Entry #2

Provide an explanation of the circumstances of the

debarment.

Section 23 - Investigations and Clearance Record - (Continued)

YES NO (If NO, proceed to 23.3)

Have you EVER had a security clearance eligibility/access authorization denied, suspended, or

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

Est.

Provide the name of the agency that took

the action.

Provide an explanation of the circumstances of the

denial,suspension or revocation action.

YES NO (If NO, proceed to Section 24)

Have you EVER been debarred from government employment?

Complete the following if you responded 'Yes' to having EVER been debarred from government employment.

Entry #1

Provide an explanation of the circumstances of the

debarment.

Enter your Social Security Number before going to the next page

Provide the date security clearance

eligibility/access authorization was denied,

suspended or revoked. (Month/Year)

Provide the date security clearance

eligibility/access authorization was denied,

suspended or revoked. (Month/Year)

Provide the date the debarment occurred.

(Month/Year)

Provide the date the debarment occurred.

(Month/Year)

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

Page 77

Section 24 - Financial Record

In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?

Provide the bankruptcy court docket/account number.

Est.

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.

Chapter 7 Chapter 11 Chapter 12 Chapter 13

Select the applicable bankruptcy petition type.

Est.

Not Applicable

Entry #1

Provide the total amount (in U.S.

dollars) involved in the bankruptcy.

Est.

Provide the name debt is recorded under.

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

Country

Zip Code

Suffix

Middle name

Last name

First name

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

Country

Zip Code

Provide the name of the trustee for this bankruptcy.

Were you discharged of all debts claimed in the bankruptcy?

Provide Explanation.

(a) If Chapter 13 or Chapter 12 previously selected:

Provide the name of the court involved.

24.1

NO (Provide explanation)YES (Provide explanation)

Provide the bankruptcy court docket/account number.

Est.

Chapter 7 Chapter 11 Chapter 12 Chapter 13

Select the applicable bankruptcy petition type.

Est.

Not Applicable

Entry #2

Provide the total amount (in U.S.

dollars) involved in the bankruptcy.

Est.

Provide the name debt is recorded under.

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

Country

Zip Code

Suffix

Middle name

Last name

First name

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

Country

Zip Code

Provide the name of the trustee for this bankruptcy.

Were you discharged of all debts claimed in the bankruptcy?

Provide Explanation.

(a) If Chapter 13 or Chapter 12 previously selected:

Provide the name of the court involved.

NO (Provide explanation)YES (Provide explanation)

Provide the date bankruptcy was

filed. (Month/Year)

Provide the date bankruptcy was

filed. (Month/Year)

Provide the date of bankruptcy

discharge. (Month/Year)

Provide the date of bankruptcy

discharge. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 78

Section 24 - Financial Record - (Continued)

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.

24.2

Entry #1

Provide a description of your financial problems due to gambling.

Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.Provide the date range of your financial problems due to gambling.

Present

Est.

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 a description of your financial problems due to gambling.

Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.Provide the date range of your financial problems due to gambling.

Present

Est.

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.

In the last seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law

or ordinance?

Provide the year you failed to file or pay your Federal, state, or other taxes.

YES NO (If NO, proceed to 24.4)

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.

File Pay Both

Did you fail to file, pay as required, or both?

Est.

Not Applicable

Entry #1

Provide the Federal, state, or other agency

to which you failed to file or pay taxes.

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.

Provide the reason(s) for your failure to file or pay required taxes. Provide the type of taxes you failed to file or

pay (such as property, income, sales, etc.).

Provide the amount (in U.S. dollars) of the taxes.

Est.

24.3

Provide the year you failed to file or pay your Federal, state, or other taxes.

File Pay Both

Did you fail to file, pay as required, or both?

Est.

Not Applicable

Entry #2

Provide the Federal, state, or other agency

to which you failed to file or pay taxes.

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.

Provide the reason(s) for your failure to file or pay required taxes. Provide the type of taxes you failed to file or

pay (such as property, income, sales, etc.).

Provide the amount (in U.S. dollars) of the taxes.

Est.

Provide date satisfied.

(Month/Year)

Provide date satisfied. (Month/Year)

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

Enter your Social Security Number before going to the next page

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

Page 79

Section 24 - Financial Record - (Continued)

In the last seven (7) years have you been counseled, warned, or disciplined for violating the terms of

agreement for a travel or credit card provided by your employer?

YES NO (If NO, proceed to 24.5)

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 a description of any action(s) you have taken to rectify this situation. If you have not taken any

action(s) provide explanation.

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

Country

Zip Code

Provide the reason(s) for the counseling, warning, or disciplinary action.

24.4

Est.

Provide the amount (in U.S. dollars)

of violation.

Entry #2

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any

action(s) provide explanation.

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

Country

Zip Code

Provide the reason(s) for the counseling, warning, or disciplinary action.

Est.

Provide the amount (in U.S. dollars)

of violation.

Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to

resolve an inability to meet financial obligations?

YES NO (If NO, proceed to 24.6)

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

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.

Provide explanation.

Provide the location of the credit counseling organization.

City

State

Telephone number

Extension

Provide the telephone number of the credit counseling organization.

International or DSN phone number

Day Night

Provide the name of the credit counseling organization or resource.

Entry #2

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.

Provide explanation.

Provide the location of the credit counseling organization.

City

State

Telephone number

Extension

Provide the telephone number of the credit counseling organization.

International or DSN phone number

Day Night

Provide the name of the credit counseling organization or resource.

24.5

Enter your Social Security Number before going to the next page

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

Page 80

Section 24 - Financial Record - (Continued)

Other than previously listed, have any of the following happened to you? (You will be asked to provide

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).

YES NO (If NO, proceed to 24.7)

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

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.

Provide the associated loan/account number(s) involved.

Est.

Did/does this financial issue include any of the following? (Select all that apply)

Entry #1

Identify/describe the type of property involved (if any).

Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.

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

Country

Zip Code

Provide the amount (in U.S. dollars) of the financial issue.

Provide the name of agency/organization/individual to which debt is/was owed.

Not Resolved

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).

24.6

YES NO (If NO, proceed to 24.7)

Provide the date the financial

issue began. (Month/Year)

Provide date the financial issue

was resolved. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 81

Section 24 - Financial Record - (Continued)

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

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.

Provide the associated loan/account number(s) involved.

Est.

Did/does this financial issue include any of the following? (Select all that apply)

Entry #2

Identify/describe the type of property involved (if any).

Provide the reason(s) for the financial issue.

Provide the current status of the financial issue.

Est.

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

Country

Zip Code

Provide the amount (in U.S. dollars) of the financial issue.

Provide the name of agency/organization/individual to which debt is/was owed.

Not Resolved

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).

YES NO (If NO, proceed to 24.7)

Provide the date the financial

issue began. (Month/Year)

Provide date the financial issue

was resolved. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 82

Section 24 - Financial Record - (Continued)

YES NO (If NO, proceed to Section 25)

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.

Provide the associated loan/account number(s) involved.

Est.

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).

Entry #1

Identify/describe the type of property involved (if any).

Provide the reason(s) for the financial issue. Provide the current status of the financial issue.Provide the amount (in U.S. dollars) of the financial issue.

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

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 name of agency/organization/individual to which debt is/was owed.

Est.

Not Resolved

Other than previously listed, have any of the following happened?

- 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).

24.7

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?

Provide date the financial issue was resolved. (Month/Year)Provide the date the financial issue began. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 83

Section 24 - Financial Record - (Continued)

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.

Provide the associated loan/account number(s) involved.

Est.

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).

Entry #2

Identify/describe the type of property involved (if any).

Provide the reason(s) for the financial issue. Provide the current status of the financial issue.Provide the amount (in U.S. dollars) of the financial issue.

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

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 name of agency/organization/individual to which debt is/was owed.

Est.

Not Resolved

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?

Provide date the financial issue was resolved.

(Month/Year)Provide the date the financial issue began. (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 84

25.1

(Month/Year)

Entry #2

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

Country

Zip Code

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide a description of the nature of the incident or offense.

(Month/Year)

Entry #1

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

Country

Zip Code

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide a description of the nature of the incident or offense.

(Month/Year)

Entry #2

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

Country

Zip Code

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide a description of the nature of the incident or offense.

25.2

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.

YES NO (If NO, proceed to 25.3)

In the last seven (7) years have you 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?

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.

Section 25 - Use of Information Technology Systems

YES NO (If NO, proceed to 25.2)

In the last seven (7) years have you illegally or without proper authorization accessed or attempted to

access any information technology system?

Entry #1

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

Country

Zip Code

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

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.

Est.

Provide a description of the nature of the incident or offense.

Provide the date of the incident.

Enter your Social Security Number before going to the next page

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

Page 85

(Month/Year)

Entry #1

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

Country

Zip Code

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide a description of the nature of the incident or offense.

(Month/Year)

Entry #2

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

Country

Zip Code

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide a description of the nature of the incident or offense.

25.3

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.

Section 25 - Use of Information Technology Systems - (Continued)

YES NO (If NO, proceed to Section 26)

In the last seven (7) years have you 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?

Provide the date of the incident.

Enter your Social Security Number before going to the next page

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

Page 86

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

this form?

YES NO (If NO, proceed to Section 27)

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 details of the nature of the action.

Provide the court name.

Provide a description of the results of the action. Provide the name(s) of the principal parties

involved in the court action.

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

Country

Zip Code

Est.

(Month/Year)

Entry #2

Provide details of the nature of the action.

Provide the court name.

Provide a description of the results of the action. Provide the name(s) of the principal parties

involved in the court action.

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

Country

Zip Code

Est.

(Month/Year)

Provide the date of the civil action.

Enter your Social Security Number before going to the next page

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

Page 87

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.

Section 27 - Association Record

Are you now or have you EVER 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?

YES NO (If NO, proceed to 27.2)

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 all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the

organization.

Provide the dates of your involvement with the organization.

No positions held

No contributions made

Provide all contributions made to the

organization, if any.

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

Country

Zip Code

27.1

Present

Est.

Entry #2

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the

organization.

Provide the dates of your involvement with the organization.

No positions held

No contributions made

Provide all contributions made to the

organization, if any.

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

Country

Zip Code

Present

Est.

To Date

(Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 88

Section 27 - Association Record - (Continued)

Have you EVER knowingly engaged in any acts of terrorism?

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.

Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by

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.

YES NO (If NO, proceed to 27.3)

27.2

Present

Est.

YES NO (Proceed to 27.4)

Present

Est.

Entry #2

Provide the reason(s) for advocating acts of terrorism.

Provide the dates of advocating acts of terrorism.

Present

Est.

27.3

Entry #2

Describe the nature and reasons for the activity.

Provide the dates for any such activities.

Present

Est.

To Date

(Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 89

Section 27 - Association Record - (Continued)

Have you 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?

YES NO (If NO, proceed to 27.5)

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 all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the

organization.

Provide the dates of your involvement with the organization.

No positions held

No contributions made

Provide all contributions made to the

organization, if any.

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

Country

Zip Code

27.4

Present

Est.

Entry #2

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the

organization.

Provide the dates of your involvement with the organization.

No positions held

No contributions made

Provide all contributions made to the

organization, if any.

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

Country

Zip Code

Present

Est.

To Date

(Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 90

Section 27 - Association Record - (Continued)

Have you EVER 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 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 all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the

organization.

Provide the dates of your involvement with the organization.

No positions held

No contributions made

Provide all contributions (in U.S. dollars)

made to the organization, if any.

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

Country

Zip Code

27.5

YES NO (If NO, proceed to 27.6)

Present

Est.

Entry #2

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the

organization.

Provide the dates of your involvement with the organization.

No positions held

No contributions made

Provide all contributions (in U.S. dollars)

made to the organization, if any.

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

Country

Zip Code

Present

Est.

To Date (Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 91

Section 27 - Association Record - (Continued)

Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?

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.

Have you EVER associated with anyone involved in activities to further terrorism?

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.

27.6

YES NO (If NO, proceed to 27.7)

Present

Est.

Entry #2

Describe the nature and reasons for the activity.

Provide the dates of such activities.

Present

Est.

YES NO

27.7

To Date

(Month/Year)

From Date (Month/Year)

To Date (Month/Year)

From Date (Month/Year)

Enter your Social Security Number before going to the next page

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

Page 92

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)

Additional Comments

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

Page 93

AUTHORIZATION FOR RELEASE OF INFORMATION

UNITED STATES OF AMERICA

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

Signature (Sign in ink)

Full name (Type or print legibly)

Other names used

Current street address Apt. #

City (Country) State

ZIP Code

Telephone number

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.

Date signed (mm/dd/yyyy)

Date of birth

Social Security Number

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

Page 94

UNITED STATES OF AMERICA

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.

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

Signature (Sign in ink)

Practitioner name

Date signed (mm/dd/yyyy)

What is the prognosis?

Signature (Sign in ink)

Full name (Type or print legibly)

Other names used

Current street address Apt. #

City (Country) ZIP Code

Telephone number

If so, describe the nature of the condition and the extent and duration of the impairment or treatment.

Dates of treatment?

Date signed (mm/dd/yyyy)

State

Social Security Number

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

Page 95

UNITED STATES OF AMERICA

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