Form 1-796 Rap Back Services Form

1-796 (06-01-2018)

OMB 1110-0067

Rap Back Services Form
Name:

DOB:

UCN/FBItt:

SID#:

RBSubID:

SSN:

EVI:.

Subscribing CRI:

Requested Service (check one) \ | Enroll •

Submitting ORI:

Replace • Cancel HU Delete Q Append I I Un-Cancel

Subscription Type: (check one) | | Civil f_J Criminal

RB Category: (check one)

• Volunteer, Child Care/School Employee [~| Non-Criminal Just'ce Employment & Licensing

1 1Criminal Justice Employment Q Criminal Justice - Investigative

fj Criminal Justice - Supervision

I ISecurityClearance Information Act

Subscription Term: (optional) [_
Expiration Date:

Opt out of In-Sta! e Notifications:

Triggering Events: (check all that apply)
• Warrant Deletion •

•Disposition

Warrant Modification

l~l Death Notice with Fingerprints

•

•

Opt Out

• Civil Retain Submission • Expunge/Partial Expungement
SOR Entry

•

SOR Deletion

•

•

Warrant Entry

SOR Modification

O Death Notice without Fingerprints 0 Criminal Retain

Attention Field (max 100 characters):

User Defined Field (max 1000 characters):

Miscellaneous Notes from Submitting Agency:

Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information isgenerally authorized under 28 U.S.C. 534. Depending on the
nature of your application, supplemental authorities include Federal statutes. State statutes pursuant to Pub. L 92-544, Presidential Executive Orders, and federal.
Providingyour fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.
Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the

Federal Privacy Actof 1974 (5 USC 552a), the requesting agency is responsible for informingyou whether disclosure is mandatory or voluntary, by what statutory or
other authority your SSAN is solicited, and what uses willbe made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals
in agency records.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your
fingerprints and associated information/biometrics may be provided to the employing, investigating,or otherwise responsible agency, and/or the FBI for the purpose of
comparing your fingerprints to other fingerprints in the FBI's NextGeneration Identification (NGI) system or its successor systems (including civil, criminal,and latent
fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated
information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints
submitted to or retained by NGI.

Routine Uses: Duringthe processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your
information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the PrivacyAct of 1974 and all applicable Routine
Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include,
but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security
clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national
security or public safety.

Additional Information: The requesting agency and/or the agency conducting the application-investigationwill provide you additional information pertinent to the
specificcircumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested
information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any systems(s) of records in which
that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).

Paperwork Reduction Act Notice

This notice isgiven underthe Paperwork Reduction Act of 1995. The Paperwork Reduction Act requires that the Federal Bureau of Investigation inform individuals and
otherentities ofthe following when asking for information. The information onthisform will document an agency's request to enroll an individual intothe Rap Back
Service. TheRap Back Service notifies authorized entitieswhena person who hasfingerprints within the FBI's Next Generation Identification system isarrested or has
criminal activity against thosefingerprints. This capability provides significant benefits intwo domains: (1) to provide timely notification to licensing, employment,
volunteer, andother non-criminal justice entities regarding events reported to the NGI system regarding theirapplicants, employees, volunteers, licensees, etc.;and(2)
to providetimely notification to criminal justiceagencies regardingevents reported to the NGI system pertainingto individuals under authorized law enforcement
investigation or under the supervision of criminaljustice agencies. The information requested is required by 28 CFR 20.1 to ensure the FBI collects, stores, and

disseminates identity history information ina mannerto ensureaccuracy, completeness, currency, integrity, and security while protecting individual privacy.

The estimate average burden associated with thiscollection is5 minutes per respondent, depending on individual circumstances. Comments concerning the accuracy
of this burdenestimate and suggestions for reducing this burdenshouldbe directedto Department Clearance Officer, United States Department ofJustice, Justice
Management Division, Policy and Planning Staff, Washington, DC 20530.

Anagency may not conduct or sponsor, and a person is not required to respond to, a collection of informationunless it displays a currently valid OMB control number.

1.

Name - Individual enrolling for Rap BackSubscription

2.

DOB-Date of Birth

3.

SSN-Social Security Number

4.

UCN/FBI#-Universal Control Number/FBItt of the individual (Replaces FBI#)

5.

SID# - State Identification Number assigned by the State Identification Bureau

6.

EVI - Event Identifier

7.
8.
9.

NCN - NGI Control Number (Replaces ICN/ECN#)
RB Sub ID- Rap Back Subscription Identification Number
Subscribing CRI - Subscribing Agency Identification Number

10. Submitting ORI - Submitting Agency Identification Number
11. Originating Agency Case Number - (CriminalSubscriptions Only) - Used to indicated Case Number Associated with
Subscription.

12. Requested Service - Type of service requested for the Rap Back Subscription
a.

Enroll - Places a Rap Back Subscription on an individual

b.

Replace- Update the existing data fields in the Rap Back Subscription. (Name, DOB, Rap Back Activity
Notification Format, Rap Back Opt-Out InState Indicator, Rap Back Attention Indicator, Rap Back
Expiration Date, Rap Back Trigger, Rap Back Recipient, Rap Back Disclosure Indicator, and Rap Back User

c.

Cancel- Used to cancel the Rap Back Subscription (must include the FBI Number/UCN and the Rap Back

Defined.

Subscription Identifier)

d.
e.

f.

Delete-Remove subscription data from the Rap BackSubscription
Append - Add additional information to the Rap BackSubscription

Un-Cancel -Re-Activate the Rap Back Subscription within 60 days of the Subscription being canceled.
(must include FBI Number/UCN and Rap Back Subscription Identifier)

13. Subscription Type - Type of Rap Back Subscription
a.

Civil

b.

Criminal

14. Rap Back Category- Identifies the correct categoryof the subscription so that NGI will use the correct PurposeCode
when generating criminal history information (onlyused for Category Based Subscriptions)
a. I- Volunteer, Child Care/School Employee, Non-Criminal Justice Employee and Licensing
b.
c.
d.
e.

J-Criminal Justice Employee
S - Security Clearance Information Act (SCIA)
CI - Criminal Justice Investigative
CS-Criminal Justice Supervision

15. Rap Back Disclosure Indicator (Criminal Subscriptions Only) - Used to indicate whether the Rap Back Subscription
should be visible on Rap Sheets generated to other criminal justice agencies.
16. Subscription Term - (optional) Term of the Rap BackSubscription
17. Activity Notification Format - Notification response designated by Subscription owner
18. Expiration Date - Date Rap Back Subscription expires and needs to be re-validated within NGI

19. Opt out of In-State Notifications - Notification not necessary ifnotifying event originated within the subscribing state
20. Rap BackTrigger - Specify which events to receive a Rap Back notification
a.
b.

Criminal Retain Submission (Default) - Retained Criminal Ten Print Submission
Dispositions - A reported disposition transaction

c.

Civil Retain Submission (Limited) - ARetained civil transaction is placed on the Identity History Summary

d.
e.
f.
g.
h.
i.
j.
k.

Expunge/Partial Expungement - Complete or partial expungement of arrest information
Want Addition- An entry is added to the NCIC Wanted Person File or ImmigrationViolator File
Want Deletion - An entry is deleted from the NCIC Wanted Person File or Immigration ViolatorFile
Want Modification - Amodification is made to an Identity HistorySummary
SexOffender Registry Addition - Arecord is entered into the SexOffender Registry
SexOffender Registry Deletion - A record is deleted from the SexOffender Registry
Sex Offender Registry Modification - Arecord is modified in the Sex Offender Registry
Death Notice with Fingerprints - NGI has received a death notice supported byfingerprints associated with a
subscribed Identity.

I.

Death Notice without Fingerprints - NGI has received a death notice not supported byfingerprints associated
with a subscribed identity.

21. Attention Field (max 50 Characters) - Contains Subscriber-designated individual or Section to whoseattention any
inquiry or notification should be directed and a 24/7 contact number.

22. Recipient Field (max 19 characters) - Contains ORI number of Recipient Agency

23. User Defined Field - Free text fields to include Field Name (50characters) and Field Text (100 Characters) for use by
agencies.