PD F 5520 Investigative Request For Educational Registrar and Dean

PD F 5520 E
Department of the Treasury
Bureau of the Public Debt

INVESTIGATIVE REQUEST FOR
EDUCATIONAL REGISTRAR AND
DEAN OF STUDENTS RECORD DATA

OMB No. 1535-0141

U.S. GOVERNMENT USE ONLY

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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.
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 suitablity 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 suitability 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, 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:

DATE OF BIRTH

SOCIAL SECURITY NUMBER

POSITION FOR WHICH INVESTIGATED

PLACE OF BIRTH:

THIS PERSON CLAIMED ATTENDANCE AS FOLLOWS
FROM (MO/YR):

SCHOOL NAME AND ADDRESS:

TO (MO/YR):
DEGREE AND DATE (MO/YR):

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
TO THE BEST OF YOUR KNOWLEDGE, IS THE INFORMATION ON THE FRONT OF THIS FORM THE SAME AS SHOWN IN YOUR
RECORDS?
a

YES

b

NO (List discrepancies in REMARKS section)

c

WE HAVE NO RECORD ON THIS PERSON

FOR INQUIRIES DIRECTED TO DEAN OF STUDENTS: DO YOUR RECORDS CONTAIN ANY ADVERSE INFORMATION RELEVANT TO
THIS PERSON?
a

YES

b

NO (Explain in REMARKS section)

REMARKS

PLEASE SIGN THIS FORM HERE:
YOUR TITLE:
DAYTIME TELEPHONE NUMBER:
(Include Area Code)

DATE: