inv100, Freedom of Information or Privacy Act Record Request Form

In the case of wanting to request background investigation records about yourself, the following form has to be completed and submitted.

Extracted Text for Proper Search

Form Approved 
OMB No. 3206-0259	
Instructions: Use of this form is optional. You may use any written format for a Freed\
om of Information (FOIA) 
or Privacy Act (PA) Request as long as it contains a description of th\
e information you are requesting and 
sufficient personally identifying data when required. Failure to provide\
 the required information may result in 
no action being taken on the request. Submit completed forms via fax, ma\
il, or e-mail as scanned attachments.  
If submitting via e-mail, you should ensure that the security of your e-\
mail system is adequate for transmitting 
sensitive information before choosing to transmit your request, which co\
ntains your personally identifiable 
information.   Mail: OPM-Federal Investigative Services; ATTN: FOI/PA office, 1137 Branchton \
Road, P.O. Box 618, 
Boyers, PA 16018.  Fax: (724) 794-4590.  e-Mail: [email protected].
U.S. Office of Personnel Management Federal Investigative Services	
Page 1 of 3	INV 100 
Sept 2015	
1. Type of Request	 - (This section must be completed.)	
2. Requester Information	 - (This section must be completed.)	
Full Name:
Street Address:
City:	Zip Code:	
Optional:	Telephone Number:	
3. Records Requested (Select One)	
 Standard Form Only (SF86, 85P, or 85)	
Other (Specify in the box below) - Attach a separate page if you need \
more space than  
provided below.	 All Investigations and Standard Forms	
 Most Recent Investigation, including Standard Form	
State:	
Country:
 PA/FOIA Request:
 FOIA Request:
 PA Amendment Request: 
Preferred Delivery Method:	e-Mail Address:  	Secure e-Mail* 	          	
I request my own records.  (Requester must complete sections 2, 3, 4, 5, and 7.)
I am making a request for records about someone or something other than \
myself. 
(Requester must complete sections 2, 3, 7, and 8.)
I wish to amend my own records.  In accordance with 5 C.F.R. § 297.30\
1, the burden of proof rests with the record subject to illustrate 
how his/her record is not accurate, timely, relevant, or complete.  Requ\
esters should attach additional material to this form.  
(Requester must complete sections 2, 4, 5, and 7.)	
FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM	
*A secure e-mail ensures that the information being sent to you is encry\
pted and therefore cannot be intercepted and read.  Many widely used \
e-mail providers 
accept this type of file.  If your e-mail provider prohibits secure e\
-mails you will be notified to register with the OPM server.  This re\
gistration process will 
authenticate your identity and will allow the e-mail to be delivered dir\
ectly to you.  
 	
Hardcopy Mail

Form Approved 
OMB No. 3206-0259 
 	
U.S. Office of Personnel Management Federal Investigative Services Page 2 of 3
INV 100 
Sept 2015
6. Optional:  Authorization to Release Information to a Third Party. 
By completing this section, you authorize information relating to you to\
 be released to another person, such as a family member or legal 
counsel.  Please note, if you choose to have your records sent to a thir\
d party, you will not be furnished a duplicate copy.   Pursuant to 5 U.S.C. 
§ 552a(b), I authorize the United States Office of Personnel Manage\
ment's, Federal Investigative Services to release my records (defined a\
bove) to:
Full Name:
Mailing Address:
7. Verification of Requester's Identity	 - (Complete this section only if you are making a request for records \
about yourself.)  	
 I declare under the penalty of perjury under the laws of the United Stat\
es of America that the foregoing is true and correct, and I am the perso\
n 
named in Section 2.  I understand that any falsification of this stateme\
nt is punishable under the provisions of 18 U.S.C. § 1001 by a fine o\
f not more 
than $10,000, or by imprisonment for not more than five years or both, a\
nd that requesting or obtaining any record(s) under false pretenses is\
 
punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fin\
e of not more than $5,000.	
 
                                                                	
8. Complete this section only if you are requesting records about someon\
e or something other than yourself. 
In the box below, you may wish to provide information about yourself and\
 the purpose of your request to help us determine your fee 
category.  While FOIA does not require a requester to state the purpose \
of a request, fees may be reduced based on the nature of the 
requester or purpose of the request.  Fees for searching, copying, and p\
rocessing records in this category may be levied in accordance with 
OPM's regulations at 5 C.F.R. § 294.109. If you are asking for a waiv\
er or reduction of fees, you can also use this box to provide an 
explanation.  Attach a separate page if you need more space than provide\
d below. 	
I agree to pay up to a specific amount for fees.         	 I agree to pay all applicable fees.	
Date:	
Country of Birth:
City of Birth:  	State of Birth:	
4. Requester's Identifying Information	 - (Complete this section only if you are making a request for records \
about yourself.)	
Social Security Number:	Date of Birth: (MM/DD/YYYY)	
Affiliated with an educational or noncommercial scientific institution a\
nd this request is not for commercial use.
Requesting the information in order to contribute significantly to the p\
ublic understanding of the operations or activities 
of the government and I do not primarily have a commercial interest in t\
he information.
A representative of the news media and this request is part of a news di\
ssemination function and not for commercial use.	
Specify the amount	
Handwritten Signature: _______________________________________	
I request a waiver or reduction of fees because I am (check all options\
 listed below that apply):	
5. Identity Source Documents - 	(Copies of two identity source documents must be submitted along with t\
his form.)	 	
Examples of acceptable identity source documents are provided on the OPM\
-Federal Investigative Services FOIA/PA web page:    https://www.opm.gov/investigations/freedom-of-information-and-privacy-ac\
t-requests/	
Copies of two identity source documents are attached.

FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM Privacy Routine Use and Disclosure Information	Form Approved 
OMB No. 3206-0259 
 	
U.S. Office of Personnel Management Federal Investigative Services Page 3 of 3
INV 100 
Sept 2015	
Privacy Act Statement. Information provided by a requester will be used to locate and provide t\
he requester responsive records pursuant to the Freedom of 
Information Act (5 U.S.C. § 552), and/or the Privacy Act of 1974 (\
5 U.S.C. § 552a). Authority to collect this information is contained\
 in 5 U.S.C. § 552, 5 U.S.C. § 552a,      
5 C.F.R. § 297.201(b). The purpose of the collection is to enable t\
he United States Office of Personnel Management (OPM) Federal Investig\
ative Services to locate 
applicable records and to respond to requests made under the Freedom of \
Information Act and the Privacy Act of 1974. Failure to provide the requ\
ired information 
may result in no action being taken on the request. 
 
Routine Uses. The information collected on this form will primarily be used to compl\
y with requests for information under Title 5 U.S. Code 552 and 552a. Ro\
utine 
uses of the records include: 
 
To disclose information to the Office of Management and Budget at any st\
age in the legislative coordination and clearance process in connection \
with private 
relief legislation as set forth in OMB Circular No. A-19. 
 
To disclose information to Federal agencies in order to obtain advice an\
d recommendations concerning matters on which the agency has specialized\
 
experience or particular competence, for use by OPM in making required d\
eterminations under the Freedom of Information Act or the Privacy Act of\
 1974. 
  To disclose information to an agency, subject to law, rule, or regulatio\
n enforced by OPM having been found in violation of such law, rule, or r\
egulation, in 
order to achieve compliance with OPM instructions. 
 
To disclose information to any source from which additional information \
is requested (to the extent necessary to identify the individual, infor\
m the source of 
the purpose of the request, and to identify the type of information requ\
ested), where necessary to obtain information relevant to an OPM decisi\
on concerning 
a Privacy or Freedom of Information Act request. 
 
To disclose to the Federal agency involved, an OPM decision on an appeal\
 from an initial denial of a request involving OPM-controlled records. 
 
To disclose pertinent information to the appropriate Federal, State, or \
local agency responsible for investigating, prosecuting, enforcing, or i\
mplementing a 
statute, rule, regulation, or order, where OPM becomes aware of an indic\
ation of a violation or potential violation of civil or criminal law or \
regulation. 
 
To provide information to a congressional office from the record of an i\
ndividual in response to an inquiry from that congressional office made \
at the request 
of that individual. 
 
To disclose information to another Federal agency, to a court, or a part\
y in litigation before a court or in an administrative proceeding being \
conducted by a 
Federal agency, when the Government is a party to the judicial or admini\
strative proceeding. In those cases where the Government is not a party \
to the 
proceeding, records may be disclosed if a subpoena has been signed by a \
judge. 
 
To disclose information to the National Archives and Records Administrat\
ion for use in records management inspections. 
 
By OPM in the production of summary descriptive statistics and analytica\
l studies in support of the function for which the records are collected\
 and 
maintained, or for related workforce studies. While published studies do\
 not contain individual identifiers, in some instances the selection of \
elements of data 
included in the study may be structured in such a way as to make the dat\
a individually identifiable by inference. 
 
To disclose information to the Department of Justice, or in a proceeding\
 before a court, adjudicative body, or other administrative body before \
which OPM is 
authorized to appear, when: (1) OPM, or any component thereof; or (2)\
 Any employee of OPM in his or her official capacity; or (3) Any emplo\
yee of OPM in his 
or her individual capacity where the Department of Justice or OPM has ag\
reed to represent the employee; or (4) The United States, when OPM det\
ermines 
that litigation is likely to affect OPM or any of its components; is a p\
arty to litigation or has an interest in such litigation, and the use of\
 such records by the 
Department of Justice or OPM is deemed by OPM to be relevant and necessa\
ry to the litigation provided, however, that the disclosure is compatibl\
e with the 
purpose for which records were collected. 
 
To disclose information to officials of the Merit Systems Protection Boa\
rd or the Office of the Special Counsel, when requested in connection wi\
th appeals, 
special studies of the civil service and other merit systems, review of \
OPM rules and regulations, investigations of alleged or possible prohibi\
ted personnel 
practices, and such other functions, e.g., as promulgated in 5 U.S.C. 12\
05 and 1206,  or as may be authorized by law. 
 
To disclose information to the Equal Employment Opportunity Commission w\
hen requested in connection with investigations into alleged or possible\
 
discrimination practices in the Federal sector, compliance by Federal ag\
encies with the Uniform Guidelines on Employee Selection Procedures or o\
ther 
functions vested in the Commission and to otherwise ensure compliance wi\
th the provisions of 5 U.S.C. 7201. 
 
To disclose information to the Federal Labor Relations Authority or its \
General Counsel when requested in connection with investigations of alle\
gations of 
unfair labor practices or matters before the Federal Service Impasses Pa\
nel. 
 
Information Regarding Disclosure of your Social Security Number (SSN) \
under Public Law 93-579, Section 7 (b).  Solicitation of SSNs by OPM is authorized 
under the provisions of Executive Order 9397, dated November 22, 1943. P\
roviding your social security number is voluntary. You are asked to prov\
ide your social 
security number only to facilitate the identification of records relatin\
g to you. Without your social security number, OPM may be unable to loca\
te records pertaining 
to you. The use of SSNs is necessary because of the large number of Fede\
ral employees, contractors, civilians and military personnel who have id\
entical names and/
or birth date and whose identities can only be distinguished by their SS\
Ns.  
 
Public Burden Statement. Public burden reporting for this collection of information is estimated \
to vary from 5 to 15 minutes with an average of 5 minutes per 
response, including time for reviewing instructions, searching existing \
data sources, gathering  the data needed, and completing and reviewing t\
he collection of 
information. Send comments regarding the accuracy of this burden estimat\
ion and any suggestions for reducing the burden to: U.S. Office of Perso\
nnel 
Management, Federal Investigative Services, Attn: OBM Number (3206-0259\
), 1900 E. Street NW, Washington, DC 20415-7900.