PD F 5519 Investigative Request for Law Enforcement Data

PD F 5519 E
Department of the Treasury
Bureau of the Public Debt

INVESTIGATIVE REQUEST FOR
LAW ENFORCEMENT 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: WE ARE CONDUCTING A BACKGROUND INVESTIGATION ON THE PERSON IDENTIFIED BELOW TO DETERMINE THIS PERSON’S ELIGIBILITY FOR FEDERAL EMPLOYMENT OR ACCESS TO CLASSIFIED INFORMATION. TO HELP 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 suitability 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.
THE U.S. DEPARTMENT OF THE TREASURY’S FEDERAL INVESTIGATIONS PROGRAM IS AN AUTHORIZED LAW ENFORCEMENT ACTIVITY REQUIRED BY STATUTE, PRESIDENTIAL EXECUTIVE ORDER AND FEDERAL REGULATIONS TO MAKE THIS
INVESTIGATIVE INQUIRY.
REQUEST COVERED BY THE SECURITY CLEARANCE INFORMATION ACT (P.L. 99-169)
REQUEST NOT COVERED BY THE SECURITY CLEARANCE INFORMATION ACT
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

CURRENT RESIDENCE

POSITION FOR WHICH INVESTIGATED:

THIS PERSON CLAIMS THE FOLLOWING CRIMINAL HISTORY RECORD AT YOUR LOCATION
DATE (MO/YR):

DATE (MO/YR):

OFFENSE:

OFFENSE:

ACTION:

ACTION:
LAW ENFORCEMENT AUTHORITY OR COURT

RESET

PLEASE COMPLETE THE ITEMS SHOWN BELOW
MARK THE FOLLOWING AS APPLICABLE:
a

WE HAVE NO RECORD ON THIS PERSON

b

RECORD INFORMATION SHOWN BELOW.

PLEASE PROVIDE DETAILS CONCERNING CRIMINAL HISTORY RECORD AND/OR OUTSTANDING WARRANTS). IF OUTSTANDING
WARRANTS) EXIST, LIST THE NATURE OF THE ORIGINAL CHARGE. PLEASE SHOW THE EXACT NATURE OF THE CHARGE - DO
NOT USE CODES OR ABBREVIATIONS.
DATE

OFFENSE

DISPOSITION AND DATE

LOCATION OF DISPOSITION (COURT & CITY)

REMARKS, ADDITIONAL INFORMATION THAT MAY HAVE A BEARING ON THIS PERSON’S ELIGIBILITY FOR FEDERAL EMPLOYMENT,
ACCESS TO CLASSIFIED INFORMATION OR ASSIGNMENT TO SENSITIVE NATIONAL SECURITY DUTIES.

PLEASE SIGN THIS FORM HERE:

DATE:

YOUR TITLE:
DAYTIME TELEPHONE NUMBER:
(Include Area Code)

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.