Form DD X735 DD X735 Release/Consent Statement

FOR OFFICIAL USE ONLY
OMB Control Number
0704-XXXX
Expiration Date:
XX-XX-XXXX

DEPARTMENT OF DEFENSE
RELEASE/CONSENT STATEMENT
Agency Disclosure Notice

The public reporting burden for this collection of information, 0704-XXXX, is estimated to average 5 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 the
burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT
AUTHORITY: 42 U.S.C. 13041, Requirement for background checks; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To comply with the requirements of the authorities listed above.
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended.
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries, Disclosure to the Department of
Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, and
Data Breach Remediation Purposes Routine Use. The DoD Blanket Routine Uses set forth at the beginning of the Office of the
Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of DoD Blanket
Routine Uses can be found online at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx The applicable system
of records notice is DMDC 24 DoD, Defense Information System for Security (DISS) (June 15, 2016, 81 FR 39032) and is located at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/799795/dmdc-24-dod/
DISCLOSURE: Mandatory. Failure to disclose the information precludes consideration of an application for employment in a
position or otherwise involved in the provision of child care services for children under the age of 18 or may form the basis for
removal from such a position if you are a current incumbent of a position working with children under the age of 18.
SECTION I - APPLICANT/EMPLOYEE DATA
1. POSITION TITLE

2. PAY PLAN

5. ORGANIZATION

6. LOCATION

7. NAME (Last, First, Middle Initial)

8. SOCIAL SECURITY NUMBER
(If required)

N E E D S

3. SERIES

D D

SECTION II - APPLICANT/ EMPLOYEE STATEMENT

4. GRADE

9. EFFECTIVE DATE
(YYYYMMDD)

6 7

I have been advised that my being hired, selected, or retained will be based upon successful completion of a criminal history
background check. I understand that the background check includes a DoD records check, FBI fingerprint check, and a check
against the State Criminal History Repository, Child Abuse/Neglect and Sex Offender Registries in each state where I have resided for
the last 5 years.
I have been advised and understand that the above mentioned checks are re-verified or completed either annually or every 5 years
(depending upon the position) while I am employed /contracted/volunteering in a position that requires regular contact with children
under the age of 18. I understand that this consent does not expire and will be utilized to conduct periodic reverification checks.
I understand that except to the extent such action has been taken, I can revoke this consent at any time. I also understand that if the
report of these checks contains adverse information, I have a right to challenge the accuracy or completeness of the information
contained therein.
By signing below, I hereby authorize
(Requesting agency)

to release my name and social security number, if required, for the purpose of conducting the required check(s).
1. SIGNATURE

DD FORM X735, 20160721 DRAFT

2. DATE (YYYYMMDD)

Adobe Designer 11