Request for ATF Background Investigation Information - RegInfo.gov

Request for ATF Background Investigation Information - RegInfo.gov

OMB NO: 1140-0105 (xx/xx/xxxx) U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives Request for ATF Background Investigati...

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OMB NO: 1140-0105 (xx/xx/xxxx)

U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives

Request for ATF Background Investigation Information

The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), Personnel Security Division (PSD), has received your background investigation information inquiry. In order for the PSD staff to process your request, the below information must be provided. Please complete this form. Once completed, scan and email it to [email protected] If this request is being made by a State or local agency, a copy of an authorization for release of information signed by the subject of the investigation and a copy of an official request for the information on agency letterhead must accompany this completed form. Last Name:

First Name:

Subject’s Information Middle Name:

Suffix:

Last Four Digits of SSN:

Other Names Used (include maiden and former names): Requesting Agency Information Date of Request:

Name of Agency Requesting Background Investigation: Reason for Requesting Background Investigation (employment, reciprocity, etc.):

Title of Position for which Subject is Applying: Agency Point of Contact (POC) (name, telephone number and e-mail address): Preferred Method of Receiving Copy of Background Investigation: Overnight Delivery (FedEx, DHL, etc.)

In Person Pick-Up

*OPM Portal

*Provide the OPM account holder’s name (If the POC does not have an OPM account, provide the name and email address of another agency representative who is authorized to receive the requested information through the OPM Portal.):

Agency Address to Forward Copies of Background Investigation Information:

Requestor Certification Federal Agency’s Certification. This request for information is being made in connection with the hiring or continued employment of an employee or contractor; the conduct of a suitability or security investigation of an employee or contractor; or the granting, renewal, suspension, or revocation of a security clearance, to the extent that the information is relevant and necessary to the hiring agency’s decision. State and Local (including the District of Columbia) Law Enforcement or Detention Agency Certification. This request for information is being made in connection with the hiring or continued employment of an employee or contractor, where the employee or contractor would occupy or occupies a position of public trust as a law enforcement officer or detention officer having direct contact with the public or with prisoners or detainees, to the extent that the information is relevant and necessary to the recipient agency’s decision. Date of Request: Requestor’s Certification (signature):

Requestor’s Name (please print):

Date of Response:

Requestor’s Title:

PSD Official Use Only PSD Representative Providing the Background Investigation Information:

ATF Form 8620.65 Revised ( )

Paperwork Reduction Act Notice This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used by ATF to document an official request received from another agency for an ATF background investigation record. The appropriate ATF office (Personnel Security Division) will maintain a copy of this form. It will be used to document the authorized disclosure of the background investigation information. The estimated average burden associated with this collection of information is 5 minutes per respondent, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management Officer, Resource Management Staff, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226. An Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information that does not display a currently valid OMB control number.

ATF Form 8620. 65 Revised ( )