Form PD F 5518 PD F 5518 Investigative Request for Personal Information

PD F 5518 E
Department of the Treasury
Bureau of the Public Debt

INVESTIGATIVE REQUEST FOR
PERSONAL INFORMATION

OMB No. 1535-0141

U.S. GOVERNMENT USE ONLY

F
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U.S. Department of the Treasury
Bureau of the Public Debt
200 Third Street, Avery 4D
Parkersburg, WV 26106

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INSTRUCTIONS: YOUR NAME HAS BEEN PROVIDED BY THE PERSON IDENTIFIED BELOW TO ASSIST IN
COMPLETING A BACKGROUND INVESTIGATION TO HELP US DETERMINE THIS PERSON’S SUITABILITY FOR
EMPLOYMENT OR SECURITY CLEARANCE. TO HELP US MAKE THIS DETERMINATION, WE ASK THAT YOU
COMPLETE ALL ITEMS ON THE BACK OF THIS FORM AND RETURN THE FORM IN THE ENCLOSED ENVELOPE.
YOU WERE LISTED AS:
NOTICE UNDER THE PRIVACY ACT: Title 5, Section 301 and Title 31, Section 321, of the U.S. Code authorizes
collection of this information. The purpose for collecting this information is to enable the Bureau of the Public Debt
(Public Debt) to make a determination about an individual's suitablility for employment or a security clearance. The
information you provide may be disclosed to the person being investigated and to other federal agencies. Furnishing
the information on this form is voluntary, but without this information, Public Debt may be unable to make a determination about the individual's suitablility for employment or a security clearance.
CERTIFICATION: THE PERSON WE ARE INVESTIGATING HAS GIVEN WRITTEN CONSENT FOR THIS
INVESTIGATIVE INQUIRY. WE KEEP THAT CONSENT ON FILE. IF A COPY IS REQUIRED IN ORDER TO COMPLETE THIS FORM, OR YOU WOULD LIKE TO KEEP YOUR IDENTITY CONFIDENTIAL, PLEASE INDICATE THIS
REQUIREMENT IN WRITING ON THE REVERSE.
COMPLETION OF THIS INVESTIGATION AS SOON AS POSSIBLE WILL HELP THIS PERSON AND THE AGENCY
PERFORM THEIR DUTIES IN A MORE TIMELY AND EFFICIENT MANNER.
FULL NAME (LAST, FIRST, MIDDLE):
OTHER NAMES USED:

POSITION FOR WHICH INVESTIGATED:
THIS PERSON CLAIMED THE FOLLOWING:

We estimate it will take you about 10 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is
displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV
26106-1328. DO NOT SEND completed form to this address. Return the form in the enclosed envelope.

RESET

PLEASE COMPLETE THE ITEMS SHOWN BELOW
HOW LONG HAVE YOU KNOWN THIS PERSON?
a

______YEARS ______MONTHS

b

I DON’T KNOW THIS PERSON (don’t complete other items)

MY ASSOCIATION WITH THIS PERSON IS/WAS AS A:
a

COWORKER

c

FRIEND

e

FORMER SPOUSE

g

RELATIVE

b

NEIGHBOR

d

SPOUSE

f

INSTRUCTOR

h

OTHER

ON THE AVERAGE, I ASSOCIATE(D) WITH THIS PERSON:
a

DAILY

c

MONTHLY

b

WEEKLY

d

TWICE A YEAR

e
f

ONCE EVERY YEAR OR 2
ONCE IN 3 OR MORE YEARS

I LAST ASSOCIATED WITH THIS PERSON:
a

0 TO 3 MONTHS AGO

c

1 TO 3 YEARS AGO

b

3 TO 12 MONTHS AGO

d

3 TO 5 YEARS AGO

e

MORE THAN 5 YEARS AGO

DOES THE INFORMATION ON THE FRONT OF THIS FORM CONCERNING THIS PERSON APPEAR TO BE CORRECT?
a

YES

b

NO — IT APPEARS TO BE INCORRECT OR INCOMPLETE (SHOW CORRECT OR ADDITIONAL DATA IN ITEM 8)

DO YOU HAVE ANY REASON TO QUESTION THIS PERSON’S HONESTY OR TRUSTWORTHINESS?
a

NO

c

I DO NOT KNOW THIS PERSON WELL ENOUGH TO RESPOND

b

YES

d

I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

DO YOU HAVE ANY ADVERSE INFORMATION ABOUT THIS PERSON’S EMPLOYMENT, RESIDENCE OR ACTIVITIES CONCERNING:
YES NO

YES NO

YES NO

a

VIOLATIONS OF THE LAW

c

ABUSE OF ALCOHOL AND/OR DRUGS

e

GENERAL BEHAVIOR OR CONDUCT

b

FINANCIAL INTEGRITY

d

MENTAL OR EMOTIONAL STABILITY

f

OTHER MATTERS

I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE
IF ADDITIONAL INFORMATION IS PROVIDED BELOW, YOU MUST FILL IN THIS MARK.
ADDITIONAL INFORMATION WHICH YOU FEEL MAY HAVE A BEARING ON THIS PERSON’S SUITABILITY FOR GOVERNMENT
EMPLOYMENT OR A SECURITY CLEARANCE. THIS SPACE MAY BE USED FOR DEROGATORY AS WELL AS POSITIVE INFORMATION.

DO YOU RECOMMEND THIS PERSON FOR GOVERNMENT SECURITY CLEARANCE OR EMPLOYMENT?
a

YES

b

NO

PRINT NAME:
PLEASE SIGN THIS FORM HERE:
DAYTIME TELEPHONE NUMBER:

c

I DON’T KNOW THIS PERSON WELL ENOUGH TO MAKE A RECOMMENDATION

YOUR TITLE:
DATE: