Form TSA Form 2825A TSA Form 2825A LEOSA Identification Card Application

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

OMB Control Number: 1652-NEW
Expiration Date: XX/XX/XXXX

LEOSA IDENTIFICATION CARD APPLICATION

INSTRUCTIONS: Qualified retiring or retired Law Enforcement Officers (LEOs) must complete Section I of this form to request a Law
Enforcement Officers Safety Act (LEOSA) Identification (ID) Card. The form must be submitted to their Organization Element Point of Contact
(POC), through their supervisory chain of command or their last Supervisory Air Marshal in Charge (SAC) of record, if already separated. The
Organization Element POC determines if the applicant is eligible to receive a LEOSA ID Card by completing Section II. If the applicant meets
the LEOSA criteria, the Organization Element POC scans the signed form and electronically forwards the completed form to the LE/FAMS
Credential Custodian. The LE/FAMS Credential Custodian must complete Section III.
SECTION I. Applicant Information and Acknowledgment
Name (Last, First, MI)
Title or Position

Date of Birth

Social Security Number

Separation Date

Email Address
Last Office/Location of Record Address
Home Phone Number

Office Phone Number

Cell Phone Number

I certify that I am not subject to any LEOSA disqualifiers as contained within 18 USC §§ 922(g) and (n) and the LEOSA definition of a
qualified retired law enforcement officer in 18 USC §§ 926C (c). I understand that a knowing and willful false statement on this form can be
punished by fine or imprisonment or both (18 USC § 1001.)
I understand that under the LEOSA, 18 U.S.C. §§ 926C, the LEOSA Identification Card does not confer or authorize any law enforcement
powers or authorize the cardholders to engage in any law enforcement activities or investigations.
I agree to not make a claim of any description including claims, actions, suits, procedures, costs, expenses, damages and liabilities against
TSA resulting from the authority to carry a concealed weapon.
The LEOSA Identification Card is the property of the United States Government. TSA reserves the right to repeal, revoke and/or confiscate
the card should it be damaged, altered, or used in an inappropriate manner.
If the LEOSA Identification Card is lost, stolen or damaged, it is my responsibility to report the incident to the Organization Element POC
immediately, but no later than 24 hours following the discovery.
In order to meet the requirements of LEOSA, I must qualify and meet the firearms requirements for carrying a concealed weapon for the
State in which I reside. I am responsible for all costs related to meeting these requirements.
If I experience an event which would disqualify me from receiving a firearm under 18 U.S.C. §§ 922(g) or (n), I will immediately notify the
Organization Element POC and the certifying entity in my State of residence.
I agree to hold TSA harmless and indemnify TSA from any resulting liability from the use, misuse, or possession of a firearm carried under
the LEOSA authority.
I understand that TSA will conduct an NCIC check at the time of my application.
I certify that I have read and understand the information provided above.
Date

Applicant Signature (must be original signature)
Supervisor (print name and title)
Email Address

Office Phone Number

Supervisor Signature

Date

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f); 18 U.S.C. § 926C. PRINCIPAL PURPOSE(S): To determine whether qualified retiring or retired LEOs are
eligible for a LEOSA Identification Card. ROUTINE USE(S): This information you provide may be shared with other government agencies in connection with the investigation
of a potential violation of a law, and for routine uses identified in the Transportation Security Administration system of records, DHS/TSA-002 Transportation Security Threat
Assessment System (T-STAS). DISCLOSURE: Voluntary; failure to furnish the requested information, including your SSN, may result in an inability to receive a LEOSA
Identification Card.
PAPERWORK STATEMENT ACT: This is a mandatory collection to participate in the LEOSA Program. The total average burden per response associated with this
collection is estimated to be approximately 5 minutes. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The control number assigned to this collection is OMB 1652- NEW, which will expire on XX/XX/XXXX. Send comments regarding this
burden estimate or collection to: TSA-11, Attention: PRA 1652-NEW, 601 South 12th Street, Arlington, VA 20598-6011.

Previous editions of this form are obsolete.

TSA Form 2825A (7/17) rev. [File: 2800.12.1]

Page 1 of 2

SECTION II. Organization Element POC Use Only
Please answer the following statements by selecting “YES” or “NO”:
Yes

No

There was a determination made or action initiated to remove, or proposal to remove, the employee from Federal
employment.

Yes

No

There was an investigation or unadjudicated charge of misconduct against the employee that could have led to the
employee's removal.

Yes

No

The employee's security clearance was suspended or revoked, or a proposal to suspend or revoke the clearance had
been initiated or issued.

Yes

No

The employee was the subject of a pending psychological fitness for duty evaluation or had been found to be not fit for
duty based on psychological reasons.

I have reviewed the four criteria with the appropriate offices and find the employee to be:
In good standing (“NO” must be selected for all statements.)
Not in good standing (An answer of “yes” to any of the above four questions will result in a determination that the employee is not in good
standing.)
Please answer the following statements by selecting “YES” or “NO”:
Yes

No

Separated from service as a LEO in good standing with TSA.

Yes

No

Before such separation, was authorized by law to engage in or supervise the prevention, detection, investigation, or
prosecution of, or the incarceration of any person for, any violation of law, and had statutory powers of arrest.

Yes

No

Before such separation, served as a LEO for an aggregate of 10 years or more; or separated from service as a LEO with
TSA, after completing any applicable probationary period of such service, due to a service-connected disability, as
determined by TSA.

Yes

No

Has not been officially found by a qualified medical professional employed by TSA to be unqualified for reasons relating
to mental health; or has not entered into an agreement with TSA in which the LEO acknowledges he or she is not
qualified under this section for reasons relating to mental health.

Yes

No

Is not under the influence of alcohol or another intoxicating or hallucinatory drug or substance.

Yes

No

Is not prohibited by Federal law from receiving a firearm. (Subject to NCIC review)

I have reviewed the six criteria with the appropriate offices and find the employee to be:
Qualified LEO
Non-Qualified LEO
Yes

No

NCIC Check completed.

Comments (If applicable)
Name & Title (print)
Signature
Date
SECTION III. Credential Custodian Use Only
Date Request Received
Dated Processed
LEOSA ID Card # (If applicable)
Comments (If applicable)
Name & Title (print)
Signature
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f); 18 U.S.C. § 926C. PRINCIPAL PURPOSE(S): To determine whether qualified retiring or retired LEOs are
eligible for a LEOSA Identification Card. ROUTINE USE(S): This information you provide may be shared with other government agencies in connection with the investigation
of a potential violation of a law, and for routine uses identified in the Transportation Security Administration system of records, DHS/TSA-002 Transportation Security Threat
Assessment System (T-STAS). DISCLOSURE: Voluntary; failure to furnish the requested information, including your SSN, may result in an inability to receive a LEOSA
Identification Card.
PAPERWORK STATEMENT ACT: This is a mandatory collection to participate in the LEOSA Program. The total average burden per response associated with this
collection is estimated to be approximately 5 minutes. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The control number assigned to this collection is OMB 1652- NEW, which will expire on XX/XX/XXXX. Send comments regarding this
burden estimate or collection to: TSA-11, Attention: PRA 1652-NEW, 601 South 12th Street, Arlington, VA 20598-6011.

TSA Form 2825A (7/17) rev. [File: 2800.12.1]

Previous editions of this form are obsolete.

Page 2 of 2