Form USM-3A Application for Special Deputation/Sponsoring Federal Ag

OMB Number _________ (Exp. ____/____)

Application for Special Deputation/
Sponsoring Federal Agency Information

U.S. Department of Justice
United States Marshals Service
1. Applicant Name (Last, First, MI):

2. Date of Birth:

3. Social Security Number:

4. Employer:
5. Employer Address - Street:
9. Work Telephone:

6. City:

7. State:

8. ZIP Code:

10. E-mail Address:

11. Job Title:

12. Job Series (If Federal Employee):

Yes

No

13. I am a citizen of the United States (includes naturalized citizen).

Yes

No

14. I am employed full-time by a federal, state, local or tribal law enforcement agency, or an agency approved by the DOJ.

Yes

No

15. I have successfully completed the following basic law enforcement training program or military equivalent
(EXCEPTION: Executive Office of United States Attorney). If not, state what course you have completed that is
(FLETC) comparable and provide documentation and/or certificate of completion:

Yes

Yes

No

No

Academy:

Course Name:

Location (City, State):

Completion Date (Month/Year):

16. I had a 5-year break in law enforcement, however, I have completed a law enforcement refresher course within the
past year of signing this application (attach certificate):
Agency:

Course Name:

Location (City, State):

Completion Date (Month/Year):

17. I have at least one year of basic law enforcement experience to include general arrest authority. (If no general arrest
authority, provide letter explaining what your authority was or is.)
Academy:

Location (City, State):

Dates (Month/Year - Month/Year):

Yes

No

18. I have not been convicted of a crime of domestic violence as defined in Title 18 U.S.C. Section 922 (g)(9) Lautenberg
Amendment.

Yes

No

19. I have qualified with my primary authorized firearm. Give full description (firearm manufacturer, model, caliber):
Description:
(Qualification date must be within 6 months of application date.)

Qualification Date (Month/Day/Year):

Yes

No

20. I have read and I agree to comply with the deadly force policy of either my agency or the Department of Justice.

Yes

No

21. I have included a copy of my employer's authorization letter stating that they concur with my participation and that the
applicant has no internal investigations pending within the organization.

To be completed by Protection Details only (person/building/assets/artifacts, etc.):
Yes

No

22. I have successfully completed the following basic protective services training program. If not, state what
course you have completed that is (FLETC) comparable and provide documentation and/or certificate of
completion.
Course Name:

Location (City, State):
(Attach certificate.)

Completion Date (Month/Year):

23. I certify that the above statements are true and accurate. (False or fraudulent information knowingly provided on this form is criminally
punishable pursuant to federal law, including Title 18 U.S.C. Section 1001.)
Signature of Applicant:

Reset Form

Date:

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Form USM-3A
Rev. 7/2012

SPONSORING FEDERAL AGENCY INFORMATION - To be completed by the sponsoring agency point of contact and signed by the sponsor.
1. Sponsoring Agency Name:

2. Sponsoring District:

3. Name of Sponsor:

4. Agency Phone Number:

5. Sponsoring Agency Address - Street:

6. City:

7. State:

9. Name of District Contact:

10. Telephone:

12. Name of Sponsored Applicant:

13. Applicant Employer:

14. Type of Request:

First Time

8. ZIP Code:

11. E-mail Address:

Renewal (Must be submitted 60 days prior to expiration date) - Exp. Date (MM/YY):

15. State sole purpose of Special Deputation. Explain the need and justification for the deputation, to include the name of the task force,
operation, or special project.

Provide full details and supporting documentation for all "NO" answers:
Yes

No

16. I have reviewed the Application for Special Deputation / Sponsoring Federal Agency Information (Form USM-3A)
submitted by the applicant for Special Deputation and verify that the statements submitted by the applicant are true
and correct.

Yes

No

17. I have ensured the applicant has read and understood the current deadly force policy from the Sponsoring Agency or
from the Department of Justice.

Yes

No

18. I have included a copy of the applicant's employer's authorization letter stating that they concur with the applicant's
participation and that the applicant has no internal investigations pending within his/her organization.

19. I certify that the above statements are true and accurate and that I have reviewed the applicant's statements. (False or fraudulent information
knowingly provided on this form is criminally punishable pursuant to federal law, including Title 18 U.S.C. Section 1001.)
Signature of Sponsor:

Date:

CLICK HERE to submit form to Spec.Dep@usdoj.gov (Attach any supporting documentation)
USMS USE ONLY - Provide full details and supporting documentation for all "NO" answers:
Yes

No

1. I have attached a copy of the favorable adjudication memorandum from the Personnel Security Branch (PSB) and the
date of adjudication. (MANDATORY for unescorted access to USMS space and use of IT systems.)
Date (Month/Day/Year):

Yes

No

SDU Staff Only:

2. I have provided the applicant with a copy of the Memorandum of Understanding (MOU) between the USMS and the
applicant's employer.
Approval

Disapproval

Application Incomplete

Signature of Chief, Special Deputation Unit:

Reset Form

Other
Date:

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Form USM-3A
Rev. 7/2012

INSTRUCTIONS TO COMPLETE THIS FORM
1. Applicants must be sponsored by a Federal Law Enforcement Agency.
2. Renewal requests must be received 60 days prior to the expiration of the current credentials.
3. Complete all fields. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on the form (for
example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability
and indicate this by marking "APPROX." or "EST."
4. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, USMS
may modify the form consistent with your intent.
5. You must use U.S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign
countries.
6. All telephone numbers must include area codes.
7. If you need additional space to complete this form, please use a separate blank sheet of paper.

Privacy Act Statement
The authority for collection of the information on this form is 28 CFR subpart T, 0.112, 28 U.S.C. 561 through 569. The USMS is authorized to
deputize selected persons to perform the functions of a Deputy U.S. Marshal whenever the law enforcement needs of the USMS so require, to
provide courtroom security for the Federal judiciary, and as designated by the Associate Attorney General pursuant to 28 CFR 0.19(a)(3). This
form serves as a record of the special deputations granted by the USMS to assist in tracking, controlling and monitoring the Special
Deputation Program. Your Social Security number is requested as an additional identifier pursuant to Executive Order 9397. Disclosure of the
information on this form is voluntary, however, failure to provide the information may result in your disqualification for special deputation.
This form may be routinely disclosed: To a federal, state or local law enforcement agency regarding that agency's USMS deputized
employees; Where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law - criminal,
civil, or regulatory in nature - the relevant records may be referred to the appropriate federal, state, local, territorial, tribal, or foreign law
enforcement authority or other appropriate entity charged with the responsibility for investigating or prosecuting such violation or charged with
enforcing or implementing such law; and as otherwise provided in USMS Privacy Act system of records notice Justice/USM-004, Special
Deputation Files, 72 FR 33515 (June 18, 2007).
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the 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 this burden estimate or any other aspects of this collection of information, including suggestions for
reducing this burden, to U.S. Marshals Service, Attn: TOD-Special Deputation Unit, 2604 Jefferson Davis Highway, Alexandria, VA 22301.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number.

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Form USM-3A
Rev. 7/2012