Form SSF 86A SSF 86A Supplemental Investigative Data

Form Approved:
O.M.B. No. 1620-0001
Expiration Date: 01/31/2011
CASE NO.

SUPPLEMENTAL INVESTIGATIVE DATA
INSTRUCTIONS

DO NOT ATTEMPT TO COMPLETE THIS FORM UNTIL YOU HAVE READ THE FOLLOWING INSTRUCTIONS
1. Answer all questions completely or check (x) the box which applies. If the question is not applicable, write "NA.'' If you do not know the answer and it cannot
be obtained from personal or family records, write ''unknown." Use the blank space on page 6 for extra details on any question for which you do not
have enough space.
2. Type or legible print an original plus two copies. All copies must bear an original signature. Initials are required at the bottom of each page.
Note: We cannot accept your form if it is not legible.
3. Consider each of your answers carefully. Accurate completion of this form will permit review of your qualifications. Your signature at the end of the form
will certify its correctness.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
Authority to collect the information sought on the accompanying form is derived from the following sources: Title 5 U.S.C. Section 301; Title 18 U.S.C. Section
3056; Executive Orders 10450, 12333, 12958 and 12968; Treasury Department Publication 71.10; and Title 31 C.F.R. Section 2.1.
The purpose of the information is to provide a basis for determining employment suitability and eligibility for access to classified documents. The information will
be used to fulfill legal record keeping requirements and for referral to other agencies on a need to know basis in their performance of duties. Submission of the
information is voluntary and failure to provide all or any part of the requested information will not be used as a basis for denying any right, benefit or privilege
allowed by law. However, failure to provide certain information may result in non-consideration for appointment or in termination on the basis of information in
the record. Information provided on this form will be kept confidential under provisions of the Privacy Act of 1974, Title 5 of the U.S.C., Section 552.
SECTION 1
APPLICANT - GENERAL PERSONAL AND PHYSICAL DATA
1. FULL NAME (LAST FIRST, MIDDLE) STATE ANY OTHER NAMES EVER USED (INCLUDE MAIDEN NAME, PREVIOUS MARRIED NAMES(S),
NICKNAMES, NAMES LEGALLY CHANGED, OR NAMES ASSUMED)

2. SOCIAL SECURITY NUMBER

3. CURRENT ADDRESS (NO., STREET, CITY, STATE AND ZIP CODE - INDICATE COUNTRY IF NOT U.S.)

4. CURRENT PHONE NO. (INCLUDE AREA CODE)

5. PERMANENT ADDRESS (NO., STREET, CITY, STATE AND ZIP CODE - INDICATE COUNTRY IF NOT U.S.)

6. PERMANENT PHONE NO. (INCLUDE AREA CODE)

7. OFFICE PHONE NO. (INCLUDE AREA CODE)

8. OFFICE EXTENSION

9. LEGAL RESIDENCE (STATE, TERRITORY, OR COUNTRY)

10. AGE

12. HEIGHT

13. WEIGHT

11. SEX

17. DATE OF BIRTH

15. COLOR EYES

18. PLACE OF BIRTH (CITY, STATE, COUNTRY)

20. OTHER THAN U.S. CITIZENSHIP
YES

14. BUILD

16. COLOR HAIR

19. PRESENT CITIZENSHIP (COUNTRY)

21. GIVE PARTICULARS CONCERNING PREVIOUS CITiZENSHIPS AS TO COUNTRY AND DATE

NO

22. DO YOU HAVE 20/20 VISION
UNCORRECTED?
YES

NO

23. DO YOU HAVE 20/20 CORRECTED
VISION?
YES
NO

24. DO YOU HAVE 20/60 VISION OR BETTER,
UNCORRECTED (SNELLEN)?
YES

NO

25. DO YOU HAVE 20/63 VISION, OR BETTER,
UNCORRECTED (BAILEY LOVIE)?
YES

SECTION 2
SELECTIVE SERVICE / MILITARY SERVICE RESERVE STATUS
1. PLACE OF REGISTRATION (CITY AND STATE)

2. REGISTRATION DATE

4. DATE RETIRED OR DISCHARGED

5. RESERVE STATUS
NONE

6. RESERVE BRANCH OF SERVICE

9. DATE RETIRED OR DISCHARGED

7. DATE ENTERED

10. SERIAL NO.

12. CURRENT LOCATION OF MILITARY RECORDS

UNITED STATES SECRET SERVICE

3. BRANCH OF SERVICE (IF APPLICABLE)

ACTIVE

INACTIVE

RETIRED

8. PLACE ENTERED

11. RANK

13. CURRENT LOCATION OF MILITARY MEDICAL RECORDS

PAGE 1

SSF 86A (DRAFT Rev. 01/2011)

This form was electronically produced by USSS
APPLICANT'S INITIALS

NO

Form Approved: O.M.B. No. 1620-0001
SECTION 3

MARITAL STATUS AND SPOUSE / COHABITANT / FIANCE INFORMATION

1. PRESENT STATUS ( CIRCLE OR MARK ANSWER). IF YOU HAVE BEEN MARRIED MORE THAN ONCE (INCLUDING ANNULMENTS) FURNISH DETAILS IN SECTION 10.
SINGLE

ENGAGED

MARRIED

SEPARATED

DIVORCED

WIDOWED

COHABITATING

2. STATE DATE PLACE AND REASON FOR ALL SEPARATIONS, DIVORCES, OR ANNULMENTS. IF EVER DIVORCED OR SEPARATED, FURNISH DETAILS IN SECTION 10 AS TO NAME AND
ADDRESS OF DIVORCED OR SEPARATED SPOUSE, NAMES AND ADDRESSES OF ANY ATTORNEYS, AND DATE, CIRCUMSTANCES, AND DISPOSITION.

THE FOLLOWING INFORMATION PERTAINS TO
WIFE, HUSBAND, FIANCE, COHABITANT, FORMER WIFE, FORMER HUSBAND, FOR ITEMS 3 THRU 25. (CIRCLE OR MARK ONE)
WIFE

HUSBAND

FIANCE

COHABITANT

FORMER WIFE

3. NAME (LAST, FIRST, MIDDLE)

FORMER HUSBAND
4. SOCIAL SECURITY NO.

5. STATE ANY OTHER NAMES EVER USED BY PERSON (INCLUDE MAIDEN NAME, PREVIOUS MARRIED NAME(S), NICKNAMES, NAMES LEGALLY CHANGED, OR NAMES ASSUMED).

INDICATE CIRCUMSTANCES (INCLUDING LENGTH OF TIME) UNDER WHICH ANY NAMES NOTED IN ITEM 5 ABOVE WERE USED. IF LEGALLY CHANGED, GIVE PARTICULARS (WHERE AND BY
WHAT AUTHORITY). RECORD THIS INFORMATION IN SECTION 10.
6. DATE OF BIRTH

7. PLACE OF BIRTH (CITY, STATE, COUNTRY)

8. DATE OF MARRIAGE/COHABITATION

9. PLACE OF MARRIAGE (CITY, STATE, COUNTRY)

10. LIVING
YES

11. CITIZENSHIP

12. FORMER CITIZENSHIP(S) (COUNTRY(IES))

14. DATE U.S. CITIZENSHIP ACQUIRED

15. WHERE ACQUIRED

18. DATE OF DEATH

19. CAUSE OF DEATH

13. IF ALIEN, ALIEN REGISTRATION NO.

16. DATE AND PLACE ARRIVAL IN U.S.

20. CURRENT ADDRESS (GIVE LAST ADDRESS, IF DECEASED)

22. OCCUPATION / POSITION

NO

17. NATURALIZATION CERTIFICATE NO.

21. RESIDENCE ADDRESS OF SPOUSE BEFORE MARRIAGE, IF OTHER THAN U.S.

23. PRESENT EMPLOYER

24. ANNUAL SALARY OR EARNINGS

25. EMPLOYER - BUSINESS ADDRESS (NUMBER, STREET, CITY, COUNTRY)

SECTION 4

PARENTS, CHILDREN AND OTHER DEPENDENTS

1. PROVIDE THE FOLLOWING INFORMATION FOR PARENTS AND ALL CHILDREN (BY BIRTH, ADOPTION, MARRIAGE) AND OTHER DEPENDENTS.
FULL NAME

RELATIONSHIP

DATE & PLACE OF BIRTH

2. NO. OF CHILDREN (INCLUDE STEPCHILDREN AND ADOPTED CHILDREN)
WHO ARE UNMARRIED, UNDER 21 YEARS OF AGE, AND ARE NOT SELFSUPPORTING.

UNITED STATES SECRET SERVICE

CITIZENSHIP

CURRENT ADDRESS

3. NO. OF OTHER DEPENDENTS (E.G. SPOUSE PARENTS STEPPARENTS ETC.)
WHO DEPEND ON YOU FOR AT LEAST 50% OF THEIR SUPPORT OR
CHILDREN OVER 21 NOT SELF-SUPPORTING.
PAGE 2

SSF 86A (DRAFT Rev. 01/2011)
APPLICANT'S INITIALS

Form Approved: O.M.B. No. 1620-0001
SECTION 5

CITIZENSHIP OF YOUR RELATIVES AND ASSOCIATES

Complete this section as it applies to you and your family and also as it applies to your spouse/cohabitant and their family if the relative or associate is/was:
- A U.S. Citizen by other than birth;
- An alien residing in the U.S.;
- Lived or currently living in a foreign country;
- Worked or currently working for a Foreign Government.
Relatives and associates are defined as spouse, parents (to include stepparents), brothers, sisters, stepbrothers, stepsisters, child (adopted also), aunts,
uncles and cousins). For extended family members (Other than spouse, parents, children, brothers and sisters), list only those who are frequently
contacted.
Please complete all requested information and use the codes below to identify proof of citizenship status:
1 - Naturalization Certificate - Provide the date issued and the location where the person was naturalized (Court, City, State and Certificate Numbers).
2 - Citizenship Certificate - Provide the location issue (City, State, Certificate).
3 - Alien Registration - Provide the date and place where the person entered the U.S.(City, State, and alien Registration Number).
4 - Other - Provide an explanation in the "Additional Information" block.
1a. ASSOCIATION

1

1b. SEX
Male

2. FULL NAME (Last, First Middle)

3. MAIDEN NAME AND/OR OTHER NAMES USED

Female
4. CODE NUMBER 5. CURRENT ADDRESS

6. NAME OF EMPLOYER

7.DATE AND PLACE OF BIRTH

9. FREQUENCY OF CONTACT

8. SSN

11. CITIZENSHIP (COUNTRY)

10. CERTIFICATE/REGISTRATION NUMBER

12. DATE/PLACE OF NATURALIZATION

13. DATE/PLACE OF ENTRY

14. ADDITIONAL INFORMATION

1a. ASSOCIATION

2

1b. SEX
Male

2. Full Name (Last, First Middle)

3.MAIDEN NAME AND/OR OTHER NAMES USED

Female
4. CODE NUMBER 5. CURRENT ADDRESS

6. NAME OF EMPLOYER

7. DATE AND PLACE OF BIRTH

9. FREQUENCY OF CONTACT

8. SSN

11. CITIZENSHIP (COUNTRY)

12. DATE/PLACE OF NATURALIZATION

10. CERTIFICATE/REGISTRATION NUMBER

13. DATE/PLACE OF ENTRY

14. ADDITIONAL INFORMATION

SECTION 6

NEIGHBOR REFERENCES (LIST TWO NEIGHBORS AT YOUR CURRENT LOCATION WHO KNOW YOU)

NAME (LAST, FIRST, MIDDLE)

SEX

COMPLETE BUSINESS ADDRESS
(NO., STREET, CITY, STATE)

COMPLETE RESIDENCE ADDRESS
(NO., STREET, CITY, STATE)

ADDRESS

ADDRESS

AREA CODE & PHONE NO.

AREA CODE & PHONE NO.

ADDRESS

ADDRESS

AREA CODE & PHONE NO.

AREA CODE & PHONE NO.

NO. OF
YEARS
KNOWN

M
F

M
F

UNITED STATES SECRET SERVICE

PAGE 3

SSF 86A (DRAFT Rev. 01/2011)
APPLICANT'S INITIALS

Form Approved: O.M.B. No. 1620-0001
SECTION 7

FINANCIAL INFORMATION

1. ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY?

YES

NO

2. IF YOUR ANSWER IS "NO" TO THE ABOVE, STATE SOURCES OF OTHER INCOME.

3. COMPLETE THE FOLLOWING FINANCIAL STATEMENT, USING DOLLAR AMOUNTS IN THE APPROPRIATE COLUMNS, DESIGNATING JOINT ASSETS AND LIABILITIES WHERE APPLICABLE.

JOINT

TOTAL AMOUNT

PERSONAL

CASH ON HAND
CASH IN BANK:

CHECKING

SAVINGS

SAFE DEPOSIT (CHECK APPROPRIATE BLOCK(S))

STOCKS AND BONDS (PRESENT MARKET VALUE)

ASSETS

REAL ESTATE (ESTIMATED MARKET VALUE)
INSURANCE VALUE (I.E. WHAT YOU WOULD RECEIVE IF YOU LIQUIDATED POLICY-NOT FACE VALUE)
AUTOMOBILES (ESTIMATED MARKET VALUE)
PERSONAL EFFECTS (FURNITURE, JEWELRY, ETC. - MARKET VALUE)
OTHER ASSETS - SPECIFY:

TOTAL ASSETS

CURRENT OBLIGATIONS

LIABILITIES

NOTES PAYABLE, (E.G., CAR LOAN, PERSONAL LOANS, ETC.)
MORTGAGES PAYABLE
OTHER DEBTS (JUDGMENTS, LIENS, ETC.)

TOTAL LIABILITIES

NET WORTH

SECTION 8

PERSONAL DECLARATIONS

ANSWER ITEMS 1 THROUGH 20 BY PLACING AN ''X'' IN THE PROPER COLUMN, IF ANY ANSWER IS ''YES'' GIVE EXPLANATION OR DETAILS IN SECTION 10.

YES

NO

1. HAVE YOU EVER BEEN INVOLVED IN ANY FORECLOSURE, BANKRUPTCY, RECEIVERSHIP PROCEEDINGS, CIVIL SUITS, JUDGMENTS?
2. DO YOU HAVE ANY OUTSTANDING FEDERAL, STATE, OR LOCAL TAX OBLIGATIONS?
3. ARE YOU NOW EMPLOYED BY OR SERVE AS AN OFFICER OF ANY POLITICAL ORGANIZATIONS?
4. PROVISIONS OF THE HATCH ACT MAKE IT UNLAWFUL FOR YOU, IF APPOINTED TO ANY POSITION IN THE FEDERAL SERVICE, TO ENGAGE IN CERTAIN
POLITICAL ACTIVITIES. ARE YOU ENGAGED AT PRESENT EITHER DIRECTLY OR INDIRECTLY IN ANY POLITICAL ACTIVITY OR ORGANIZATION?
5. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY FOREIGN OR DOMESTIC ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP, OR
COMBINATION OF PERSONS WHICH IS TOTALITARIAN, FASCIST, COMMUNIST, OR SUBVERSIVE; OR WHICH HAS ADOPTED OR SHOWS A POLICY
ADVOCATING OR APPROVING THE COMMISSION OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE
CONSTITUTION OF THE UNITED STATES, OR WHICH SEEMS TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL
MEANS?
6. HAVE YOU EVER BEEN A MEMBER OF, OR SUPPORTED, OR HAD ANY CONNECTIONS WITH A FOREIGN INTELLIGENCE ORGANIZATION OR ITS
ACTIVITIES?

UNITED STATES SECRET SERVICE

PAGE 4

SSF 86A (DRAFT Rev. 01/2011)
APPLICANT'S INITIALS

Form Approved: O.M.B. No. 1620-0001
SECTION 8

PERSONAL DECLARATIONS, CONTINUED FROM PAGE 4

YES
7.

ARE YOU DIRECTLY OR INDIRECTLY CONNECTED WITH THE OPERATION OF ANY PRIVATE OR COMMERCIAL ENTERPRISE WHICH SELLS OR
OTHERWISE CONTRACTS FOR INVESTIGATIVE SERVICES OF ANY KIND FOR PRIVATE INDIVIDUALS OR BUSINESS FIRMS?

8.

ARE THERE ANY INCIDENTS IN YOUR OWN BACKGROUND, OR THAT OF MEMBERS OF YOUR FAMILY, WHICH MIGHT COMPROMISE YOUR
PERFORMANCE AS A SECRET SERVICE EMPLOYEE?

9.

HAVE YOU EVER BEEN THE SUBJECT OF ANY EMPLOYEE DISCIPLINARY ACTION?

NO

10. HAVE YOU EVER BEEN EVICTED FROM A RESIDENCE?
11. HAVE YOU EVER BEEN THE SUBJECT OF A FORMAL COMPLAINT SUBMITTED TO A POLICE DEPARTMENT?
12. HAVE YOU EVER BEEN THE SUBJECT OF A FORMAL COMPLAINT SUBMITTED TO YOUR EMPLOYER, IN REGARD TO YOUR CONDUCT ON OR OFF THE
JOB ?
13. HAVE YOU EVER BEEN ARRESTED?
14. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME?
15. DO YOU USE ILLEGAL DRUGS?
16. HAVE YOU EVER ILLEGALLY USED MARIJUANA?
17. HOW MANY TIMES HAVE YOU ILLEGALLY USED MARIJUANA?
18. WHEN DID YOU LAST ILLEGALLY USE MARIJUANA?
19. HAVE YOU EVER ILLEGALLY USED SUCH ITEMS AS HASHISH, COCAINE, LSD, AMPHETAMINES, HEROIN, OR DRUGS OF A SIMILAR NATURE (DO NOT
INCLUDE MARIJUANA)? [CIRCLE OR MARK WHICH DRUG(S)]
20. HAVE YOU EVER FACILITATED THE TRANSACTION OF ILLEGAL DRUGS?

SECTION 9

INCOME TAX STATUS

1. FEDERAL INCOME TAX RETURNS WERE FILED FOR EACH OF THE PAST 3 YEARS AS FOLLOWS:
FOR YEAR

IRS COLLECTION DISTRICT

NAME(S) ON RETURN

ADDRESS ON RETURN

2. IF NO RETURN(S) WERE FILED FOR ANY YEAR INDICATED ABOVE, FURNISH DETAILS FOR THAT YEAR IN SECTION 10 OF THIS FORM.
NOT APPLICABLE

SEE SECTION 10

3. IF SPOUSE FILED SEPARATE RETURN(S) FOR ANY YEAR INDICATED ABOVE, FURNISH DETAILS FOR THAT YEAR IN SECTION 10 OF THIS FORM AS TO DISTRICT IN WHICH FILED AND NAME
AND ADDRESS USED ON RETURN(S).
NOT APPLICABLE

SEE SECTION 10

4. IF SPOUSE HAD INCOME DURING THE 3 YEAR PERIOD, STATE BRIEFLY IN SECTION 10 OF THIS FORM AS TO SOURCE AND AMOUNT OF INCOME DURING THAT PERIOD.
NOT APPLICABLE

SEE SECTION 10

CONTINUE ON THE FOLLOWING PAGE. PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING.
SPACE FOR EXTRA DETAILS CONTINUED ON PAGE 6.

UNITED STATES SECRET SERVICE

PAGE 5

SSF 86A (DRAFT Rev. 01/2011)
APPLICANT'S INITIALS

Form Approved: O.M.B. No. 1620-0001
SECTION 10
EXTRA DETAILS

USE THE FOLLOWING SPACE FOR EXTRA DETAILS. REFERENCE EACH CONTINUED ITEM BY THE SECTION AND ITEM NUMBER TO WHICH IT RELATES.
SECTION
#

ITEM
#

YOU ARE INFORMED THAT THE ACCURACY OF ANY STATEMENT MADE IN THIS APPLICATION MAY BE INVESTIGATED.
ATTENTION: READ THE FOLLOWING CAREFULLY BEFORE SIGNING
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 DECISION OR ACTION AGAINST YOU, INCLUDING LOSS OR DENIAL OF
EMPLOYMENT; HOWEVER, WITH RESPECT TO SECTION 8, QUESTIONS 5-6 AND 15-20, NEITHER YOUR TRUTHFUL RESPONSES NOR
INFORMATION DERIVED FROM THOSE RESPONSES WILL BE USED AS EVIDENCE AGAINST YOU IN A SUBSEQUENT CRIMINAL
PROCEEDING.

CERTIFICATION: I CERTIFY THAT ALL THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND ARE
MADE IN GOOD FAITH.
DATE SIGNED

SIGNATURE OF APPLICANT

SIGNATURE OF WITNESS (U. S. SECRET SERVICE EMPLOYEE ONLY)

OFFICE ASSIGNED

DATE SIGNED

PUBLIC BURDEN INFORMATION
3
The estimated average burden associated with this collection of information is
hours per respondent or recordkeeper.
Comments and or suggestions concerning the accuracy of this burden estimate and for reducing this burden should be
directed to the U.S. Secret Service, Management and Organization Division, Policy Analysis and Organizational Development
Branch, Suite 7800, 950 H Street, NW, Washington, DC 20223; and to the Office of Management and Budget, Paperwork
Reduction Project (1620-0001), Washington, DC 20503. An agency may not conduct or sponsor, and a person is not required
to, a collection of information unless the collection of information displays a valid OMB control number.

UNITED STATES SECRET SERVICE

PAGE 6

SSF 86A (DRAFT Rev. 01/2011)
APPLICANT'S INITIALS