Electronic Processing Questionnaire

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 ARCHIVAL COPY - RETAIN FOR YOUR RECORDS
The information contained in this document represents data submitted by Lilly Aguiar (Applicant) for the e-QIP Investigation Request #9991746. Applicant certified the accuracy of this information at 2011-04-12 19:52:55.330. This Investigation Request contains the following documents: Page 1: Investigation Request Cover Sheet Page 2-24: Questionnaire for National Security Positions (SF86 Format) Note: To conserve paper only the first entry in multiple-entry
lists displays completion instructions. The completion instructions for the first entry also applies to each additional entry unless otherwise noted.

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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Form Completion Instructions

Questionnaire for National Security Positions (SF86 Format)
OMB No. 3206-0005 Follow instructions fully or we cannot process your form. If you have any questions, contact the office that gave you the form.

Purpose of this Form
The United States (U.S.) Government conducts background investigations and reinvestigations of persons under consideration for or retention in national security positions as defined in 5 CFR 732 and for positions requiring access to classified information under Executive Order 12968. Giving us this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely affect your eligibility for a national security position. Any information that you provide is evaluated on the basis of its recency, seriousness, relevance to the position and duties, and consistency with all other information about you. Withholding, misrepresenting, or falsifying information will have an impact on a security clearance, employment prospects, or job status, up to and including denial or revocation of your security clearance, or your removal and debarment from Federal Service. This form is a permanent document that may be used as the basis for future investigations, security clearance determinations, and determinations of your suitability for employment. Your responses to this form may be compared with previous security questionnaires. It is imperative that the information provided be true and accurate to the best of your knowledge.

Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders 10450, 10865, 12333, and 12968; sections 3301, 3302, and 9101 of title 5, U.S. Code (U.S.C.); sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50, U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal Regulations. Your Social Security Number (SSN) is needed to identify your unique records. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397.

The Investigative Process
Background investigations for national security positions are conducted to gather information to show whether you are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide on this form may be confirmed during the investigation. The investigation may extend beyond the time covered by this form when necessary to resolve issues. Your current employer may be contacted as part of the investigation, even if you have previously indicated on applications or other forms that you do not want your current employer to be contacted. In addition to the questions on this form, inquiry also is made about your adherence to security requirements, honesty and integrity, vulnerability to exploitation or coercion, falsification, misrepresentation, and any other behavior, activities, or associations that tend to show the person is not reliable, trustworthy, or loyal. Checks of Federal agency records may be made about your spouse or other cohabitant.

Your Personal Interview
Some investigations will include an interview with you as a routine part of the investigative process. The investigator may ask you to explain your answers to any question on this form. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often helps to complete your investigation faster. It is important that the interview be conducted as soon as possible after you are contacted. Postponements will delay the processing of your investigation, and declining to be interviewed may result in your investigation being delayed or canceled. For the interview, you will be asked to bring identification with your picture on it, such as a valid state driver's license. There are other documents you may be asked to bring to verify your identity as well. These may include documentation of any legal name change, Social Security card, passport, and/or your birth certificate. Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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You may also be asked to bring documents about information you provided on the form or about other matters requiring specific attention. These matters include (a) alien registration or naturalization documentation; (b) delinquent loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support, alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court records.

Special Instructions for Completing this Form
Questions on this form related to residence, employment and education will require 7 years of information except that Single-Scope Background Investigations (SSBI) will require 10 years of information. Provide 7 years of information unless you have been instructed to provide 10 years to satisfy SSBI requirements. If you are unsure as to the amount of information to provide, contact the office that gave you this form. The instructions for these questions specify a 10-year time frame when an SSBI is required. If you have any questions about this investigative request or whether the 7-year time frame or the 10-year time frame applies to your responses to these questions, contact the office that gave you this form.

Instructions for Completing this Form
1. Follow the instructions given to you by the office that gave you this form and any other clarifying instructions furnished by that office to assist you in completion of this form. You must sign and date, in ink, the original and each copy you submit.You should retain a copy of the completed form for your records. 2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box unless otherwise noted. 3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country list feature. To use the country list feature, click on the "List" link beside the "Country" title to open a listing of country names in a separate window. Find the desired country name and use your web browser's "Copy" and "Paste" features to copy the country name into the "Country" text field. If the country name is not in the list, manually enter the country name into the "Country" text field. When entering a U.S. address or location, select the state or territory from the "States" pull-down list. Selecting a state/territory implies "United States" as the country, so you do not need to enter it into the "Country" text field. For locations outside of the U.S. and its territories, enter the name of the country into the "Country" text field and leave the "State" field blank. 4. The 5-digit postal Zip Codes are needed to speed the processing of your investigation. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes. 5. For telephone numbers in the U.S., be sure to include the area code. 6. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the pull down lists to select the month and day. The year should be entered as all four numbers, i.e., 1978 or 2001. If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by checking the "Est." box.

Final Determination on Your Eligibility
Final determination on your eligibility for a national security position is the responsibility of the Federal agency that requested your investigation. You will be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made.

Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to 5 years of imprisonment. In addition, Federal agencies generally fire, do not grant a security clearance, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Your prospects of placement or security clearance are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you give to us on this form and to make your comments part of the record.

DISCLOSURE INFORMATION
Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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The information you give to us is for the purpose of investigating you for a national security position; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information is governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses published by the agency in the Federal Register. The office that gave you this form will provide you a copy of its routine uses.

PRIVACY ACT ROUTINE USES
1. To the Department of Justice when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records by the Department of Justice is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records. 2. To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records. 3. Except as noted in Question 23 and 27, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order. 4. To any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested. 5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an employee, or the retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action. 6. To contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged. Such recipients shall be required to comply with the Privacy Act of 1974, as amended. 7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted invasion of personal privacy. 8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders or directives. 9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained. 10. To the National Archives and Records Administration for records management inspections conducted under Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 44 U.S.C. 2904 and 2906.

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11. To the Office of Management and Budget when necessary to the review of private relief legislation.

PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information is estimated to average 120 minutes per response, including 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 any other aspect of this collection of information, including suggestions for reducing this burden, to OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street N.W., Washington, DC 20415. Do not send your completed form to this address; send it to the office that provided you the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Sections 1-7: Your Identifying Information
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING THE FOREGOING INSTRUCTIONS.

Section 1: Full Name
If you have only initials in your name, enter them and select Initial Only (IO). If you have no middle name, select No Middle Name (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix. Full name Last: Aguiar First: Lilly Middle: (NMN) Suffix:
. . .

Field is blank!

Section 2: Date of Birth
Date of birth Month/Day/Year: 05/09/1990
.

Section 3: Place of Birth
Place of birth City: Miami County: Miami Dade State: FL Country:
. . .

Field is blank!

Section 5: Other Names Used
Have you used any other names? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If "Yes," give other names used and the period of time you used them [for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(s)]. If the other name is your maiden name, check the "maiden name" box. Other names used (No Entry Provided)

Section 6: Mother's Maiden Name
Mother's maiden name Last: Garcia First: Fatima Middle: Liliana
. . .

Section 7: Your Identifying Information
Height (feet): 5 (inches): 3 Weight: 103 Hair color: Black Eye color: Brown Sex Female: { x } Male: { }
. . . . . Box IS Checked! . Box NOT Checked!

.

Section 8: Your Contact Information
Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 Home e-mail address: [e-mail] Work e-mail address: [e-mail]
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Indicate when you can be reached at each phone number. Home telephone International or DSN: { } Number: Extension: Time: Work telephone International or DSN: { } Number: Extension: Time: Mobile telephone International or DSN: { } Number: 3053036355 Extension: Time: Evening
Box NOT Checked! .

Field is blank!

Field is blank!

Field is blank!

Box NOT Checked!

.

Field is blank!
Field is blank!

Field is blank!

Box NOT Checked!

.

.

Field is blank!

.

Section 9: Citizenship
Mark the box that reflects your current citizenship status and follow its instructions. Current citizenship status I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.: { x } I am a U.S. citizen or national by birth, born outside the U.S. Go to 9A: { } I am a naturalized U.S. citizen. Go to 9B or 9C: { } I am not a U.S. citizen. Go to 9D: { } U.S. Passport
Box IS Checked! Box NOT Checked! . Box NOT Checked! . Box NOT Checked! .

.

Current or most recent passport. Passport number: 044777768 Date issued Month/Day/Year: 11/22/1996 Expired? Yes: { x } No: { } Alien Registration Number Alien registration number ( Not Applicable: { x } ) :
. . Box IS Checked! . Box NOT Checked! . Box IS Checked! .

Field is blank!

Item 9A: Documentation of U.S. Citizens Born Abroad [State Department Form (FS) 240, DS 1350, FS 545, etc.]
Report information, if applicable. Date form was completed Month/Day/Year: ~ / ~ / ~ Document number: Place of issuance City: State: Country:
Field is blank! Field is blank! Field is blank! Field is blank!

.

Item 9B: Citizenship
Certificate
Where was this certificate issued? Court: Location City: State: Certificate number: Date issued Month/Day/Year: ~ / ~ / ~
Field is blank! Field is blank! Field is blank! Field is blank!
.

Item 9C: Naturalization Certificate
Where was this certificate issued? Court: Location City: State: Certificate number: Date issued
Field is blank! Field is blank! Field is blank! Field is blank!

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 Month/Day/Year: ~ / ~ / ~

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Item 9D: Immigration Status
Place you entered the U.S. Location City: State: Date of entry Month/Day/Year: ~ / ~ / ~ Type of document (I-94, etc.): Document number: Country(ies) of citizenship (No Entry Provided)
Field is blank! Field is blank! Field is blank! Field is blank!

.

Section 10: Citizenship Information
Do you now hold or have you EVER held multiple citizenships? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes," provide responses for the following questions. If "No", go to Section 11.

Item 10A
Provide the name(s) of the country(ies). Country(ies) of citizenship (No Entry Provided)

Item 10B
During what periods of time did you hold multiple citizenships (month/year)? Time periods
Field is blank!

Item 10C
Is your non-U.S. citizenship based on your birth in a foreign country or the citizenship of your parents? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If "No," explain. Explanation
Field is blank!

Item 10D
Have you renounced or attempted to renounce your foreign citizenship(s)? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If "Yes," explain. Explanation
Field is blank!

Section 11: Where You Have Lived
List the places where you have lived, beginning with your present residence and working back 7 years (if an SSBI go back 10 years). Residences for the entire 7 year period must be accounted for without breaks. You may omit temporary military duty locations (TDY) under 90 days (list your address of record instead), but you must list other part-time residences. Do not list residences before your 18th birthday unless to provide a minimum of 2 years of residence history.

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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1.

Provide the requested information about this place where you have lived. Indicate the actual physical location of your residence. Do not use a Post Office Box as an address, and do not list a permanent address when you were actually living at a school address, etc. Be sure to be as specific as possible when listing an address location: for example, do not list only your base or ship, list your barracks number or home port. Your actual physical location in addition to your APO/FPO address is required for overseas assignments. For addresses in the last 3 years, if the address is "General Delivery," a Rural or State Route, or may be difficult to locate, provide directions for locating the residence under Additional Comments below. Include apartment numbers if applicable.

Residence Information
Dates of activity From (Month/Year): 01/1998 (Estimated) To (Month/Year): Present Status Own: { x } Rent: { } Military housing: { } Other (Explain): { } Explanation
. Box IS Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . .

Field is blank!

Street address/APO address/FPO address Street: 3116 NW 18 TR City: Miami State: FL Country: Zip Code: 33125
. . .

Field is blank!

.

Point of Contact for this Period of Residence
For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area. Do not list people for residences completely outside this 3-year period, and do not list your spouse, former spouse, or other relatives. Name of person who knows you at this address: Lourdes Morera Relationship Neighbor: { } Friend: { x } Landlord: { } Business associate: { } Other (Explain): { } Explanation
. Box NOT Checked! . Box IS Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! .

Field is blank!

Current street address/APO address/FPO address (if currently applicable) Street: 1220 SW 5TH ST APT 9 City: Miami State: FL Country: Zip Code: 33135 Telephone International or DSN: { } Number: 7863445420 Extension: Alternate contact International or DSN: { } Number: Extension:
. . .

Field is blank!

.

Box NOT Checked!

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Field is blank!

Box NOT Checked!

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Field is blank!

Field is blank!

(End of List)

Section 12: Where You Went To School
School Information
List all schools you have attended, beginning with the most recent and working back 7 years (if an SSBI go back 10 years). If your most recent degree or diploma was received more than 7 years ago (10 years for an SSBI), list it below no matter when it was received. Schools Attended ( Not Applicable: { } )
Box NOT Checked! .

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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1.

Provide the requested information about this school you attended. List college or university degrees and the dates they were received. For Correspondence/Distance/Extension/Online School, provide the address where the records are maintained. Dates of activity From (Month/Year): 08/2008 To (Month/Year): Present
.
.

Select the most appropriate type that describes your school. School type High School: { } College/University/Military College: { x } Vocational/Technical/Trade School: { } Correspondence/Distance/Extension/Online School: { } Name of school: Miami Dade College Street address of school Street: 300 NE 2ND AVE City: Miami State: FL Country: Zip Code: 33132
Box NOT Checked! . Box IS Checked! . Box NOT Checked! . Box NOT Checked! . . . .

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Field is blank!

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Degree/diploma received? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If "Yes," identify type of degree/diploma received and date awarded. Degree/diploma (No Entry Provided)

Person Who Knows You
For schools you attended in the last 3 years, list a person who knew you at school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. Name: Jennifer Sanchez Current address Street: 1504 NW 21ST AVE City: Gainesville State: FL Country: Zip Code: 32609 Telephone International or DSN: { } Number: Extension:
. . . .

Field is blank!

.

Box NOT Checked!

.

Field is
blank!

Field is blank!

2.

Dates of activity From (Month/Year): 08/2004 (Estimated) To (Month/Year): 06/2008 School type High School: { x } College/University/Military College: { } Vocational/Technical/Trade School: { } Correspondence/Distance/Extension/Online School: { } Name of school: Miami Senior High School Street address of school Street: 2450 SW 1ST ST City: Miami State: FL Country: Zip Code: 33135
. Box IS Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . . . . .

.

Field is blank!

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Degree/diploma received? Yes: { x } No: { }
Box IS Checked! . Box NOT Checked! .

Degree/diploma 1. Degree/diploma: High School Diploma or equivalent Other degree/diploma: Date awarded
Field is blank!
.

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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(End of Degree/diploma List)

Person Who Knows You
Name: Jorge Morera Current address Street: 1220 5TH ST APT 9 City: Miami State: FL Country: Zip Code: 33135 Telephone International or DSN: { } Number: 3053030947 Extension:
. . . .

Field is blank!

.

Box NOT Checked!

.

.

Field is blank!

(End of List)

Section 13: Employment Activities
List all your employment activities, beginning with the present (#1) and working back 7 years (if an SSBI go back 10 years). You should list all full-time and part-time work, paid or unpaid, consulting/contracting work, all military service duty locations, temporary military duty locations (TDY) over 90 days, self-employment, other paid work, and all periods of unemployment. The entire period must be accounted for without breaks. EXCEPTION: Do not list employments that occurred before your 18th birthday unless it is necessary for providing a minimum of 2 years of employment history. Employer/Verifier Information. List the business name of your employer or the name of a person who can verify your self-employment or unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in your military duty locations or home ports. If you are a Federal Contractor, list company name, not Federal agency. Additional Periods of Activity. Complete this block if you worked for an employer on more than one occasion at the same physical location. After entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.

Section 13A: Employment/Unemployment Information
List all your employment activities, beginning with the present and working back 7 years (if an SSBI go back 10 years). You should list all full-time and part-time work, paid or unpaid, consulting/contracting work, all military service duty locations, temporary military duty locations (TDY) over 90 days, self-employment, other paid work, and all periods of unemployment. The entire period must be accounted for without breaks. EXCEPTION: Do not list employments that occurred before your 18th birthday unless it is necessary for providing a minimum of 2 years of employment history. 1.

Employment Information
Dates of employment From (Month/Year): 08/2004 To (Month/Year): Present
. .

Check the appropriate box listed below to identify the type of employment. Type of employment Active military duty stations: { } National Guard/Reserve: { } U.S.P.H.S. Commissioned Corps: { } Other Federal employment : { } State Government (Non-Federal employment): { } Self-employment (include business name and/or name of person who can verify): { } Unemployment (include name of verifier): { x } Federal Contractor: { } Other (explain): { }
Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! Box IS Checked! . Box NOT Checked! . Box NOT Checked! .

.

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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List the name of a person who can verify your unemployment. Name of verifier: Luis Pinel Address of verifier Street: 3116 NW 18 TR City: Miami State: FL Country: Zip Code: 33125 Telephone International or DSN: { } Number: 3052443280 Extension: Additional comments I have no employment or unemployment history information. I'm a full-time student.
. . . .

Field is blank!

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Box NOT Checked!

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Field is blank!

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(End of List)

Additional comments I have no previous employment or unemployment history. I'm a full-time college student List below if applicable. Former Federal Services ( Not Applicable: { x } ) (No Entry Provided)
Box IS Checked! .

.

Section 13B: Former Federal Service, Excluding Military Service, Not Indicated Previously

Section 13C: Employment Record
1. Has any of the following happened to you in the last 7 years? 1. 2. 3. 4. 5. 6. Fired from a job Quit a job after being told you would be fired Left a job by mutual agreement following charges or allegations of misconduct Left a job by mutual agreement following notice of unsatisfactory performance Left a job for other reasons under unfavorable circumstances Laid off from job by employer Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If "Yes," provide an entry for each occurrence. (No Entry Provided) 2. Have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

3. Have you received a written warning, been officially reprimanded, suspended, or disciplined for violating a security rule or policy? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to either question, provide an entry for each incident. (No Entry Provided)

Section 14: Selective Service Record
a. Are you a male born after December 31, 1959? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question a, answer the following question. If "No," go to Section 15. b. Have you registered with the Selective Service System (SSS)? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

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Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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If "Yes," provide your registration number below. If "No," explain the reason for not registering below. Please consult the SSS if you are unaware of your status before signing this form. Registration number: Explanation
Field is blank! Field is blank!

Section 15: Military History
Account for all of your military service through the questions below. If you answer "No" to both 15a and 15b, go to Section 16. a. Have you EVER served in the U.S. military or the U.S. Merchant Marine? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

b. Have you EVER served in a foreign country's military, security forces, merchant marine, militia, or other defense forces? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question a or b, list all details of your military service below. If you had a break in service, each separate time of service should be listed. Military Service (No Entry Provided) c. Have you EVER received a discharge that was not honorable? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

d. In the last 7 years (if an SSBI go back 10 years), have you been subject to court martial or other disciplinary proceedings under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast, etc.) Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If you answered "Yes" to question d, provide an entry for each charge. Military Charges (No Entry Provided)

Section 16: People Who Know You Well
List three people who know you well and who preferably live in the U. S. They should be friends, peers, colleagues, college roommates, associates, etc., who are collectively aware of your activities outside of the workplace, school, or neighborhoods and whose combined association with you covers at least the last 7 years. Do not list your spouse, former spouse(s), other relatives, or anyone listed elsewhere on this form. 1. Dates known From (Month/Year): 09/2007 (Estimated) To (Month/Year): Present Reference name: Darwhin Paladino Relationship to you (Check all that apply) Neighbor: { } Friend: { x } Work associate: { } Schoolmate: { x } Other (Explain): { } Explanation
. . Box NOT Checked! . Box IS Checked! . Box NOT Checked! . Box IS Checked! . Box NOT Checked! .

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Field is blank!

Include apartment number, if applicable. Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 Home or work address Street: 5841 SW 5 TR City: Miami State: FL Country: Zip Code: 33144 Telephone International or DSN: { } Number: 7863444150 Extension: Time: Evening Alternate telephone International or DSN: { } Number: Extension:
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Field is blank!

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2.

Dates known From (Month/Year): 10/2008 To (Month/Year): Present Reference name: Octavila Paz Relationship to you (Check all that apply) Neighbor: { x } Friend: { } Work associate: { } Schoolmate: { } Other (Explain): { } Explanation
. . Box IS Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! .

.

Field is blank!

Home or work address Street: 3116 NW 18 TR City: Miami State: FL Country: Zip Code: 33125 Telephone International or DSN: { } Number: 3054672500 Extension: Time: Evening Alternate telephone International or DSN: { } Number: Extension:
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3.

Dates known From (Month/Year): 08/2007 (Estimated) To (Month/Year): Present Reference name: Rodrigo Pena Relationship to you (Check all that apply) Neighbor: { } Friend: { x } Work associate: { } Schoolmate: { x } Other (Explain): { } Explanation
. . Box NOT Checked! . Box IS Checked! . Box NOT Checked! . Box IS Checked! . Box NOT Checked! .

.

Field is blank!

Home or work address Street: 409 SW 8TH AVE APT 7 City: Miami State: FL Country: Zip Code: 33130 Telephone International or DSN: { } Number: 7868386408 Extension: Time: Evening Alternate telephone International or DSN: { } Number: Extension:
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(End of List)

Section 17: Marital Status
Mark one box to show your current marital status. Marital Status Never married: { x } Married (include Common Law): { } Separated: { }
Box IS Checked! . Box NOT Checked! . Box NOT Checked! .

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 Annulled: { } Divorced: { } Widowed: { }
Box NOT Checked! Box NOT Checked! Box NOT Checked!

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Item 17A. Current Spouse
If applicable, complete the following about your current spouse only. Current Spouse ( Not Applicable: { x } ) (No Entry Provided)
Box IS Checked! .

Item 17B. Former Spouse(s)
Complete the following about your former spouse(s). Former Spouse(s) ( Not Applicable: { x } ) (No Entry Provided)
Box IS Checked! .

Item 17C. Cohabitant
[A cohabitant is a person with whom you share bonds of affection, obligation, or other commitment, as opposed to a person with whom you live for reasons of convenience (a roommate)]. If applicable, complete the following about your cohabitant. Cohabitant ( Not Applicable: { x } ) (No Entry Provided)
Box IS Checked! .

Section 18: Relatives
Give the full name and other requested information, if applicable, for each of your relatives, living or deceased, specified below. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. Mother Father Stepmother Stepfather Foster parent Child (include adopted and foster) Stepchild Brother Sister Stepbrother Stepsister Half-brother Half-sister Father-in-law Mother-in-law Guardian Relationship type: Mother
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If no first name or middle name is used, select No First Name (NFN) or No Middle Name (NMN), as appropriate. If only an initial is used as the first name or middle name, enter the initial (without the period) and select Initial Only (IO). If this person is a "Jr.," "Sr.," etc., enter this under Suffix. Full name Last: Aguiar First: Fatima Middle: Liliana Suffix: Deceased Yes: { } No: { x } Date of birth Month/Day/Year: 11/17/1958 Place of birth City: Danli State: Country: Honduras Current address Street: 3116 NW 18 TR
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Box NOT Checked!

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Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 City: Miami State: FL Country: Zip Code: 33125 Country(ies) of citizenship
. .

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1. 2.

Country(ies) of citizenship: Country: United States Country(ies) of citizenship: Country: Honduras
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(End of Country(ies) of citizenship List)

If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below. Type of document FS 240 or 545: { } Citizenship certificate: { } DS 1350: { } Naturalization certificate: { x } Alien registration: { } U.S. Passport: { } Other (Explain): { } Explanation
Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box IS Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! .

Field is blank!

Document number: 448217141 2.
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Relationship type: Father Full name Last: Aguiar First: Jose Middle: Ramon Suffix: Deceased Yes: { } No: { x } Date of birth Month/Day/Year: 05/25/1967 Place of birth City: Havana State: Country: Cuba Current address Street: 72 NW 17 CT City: Miami State: FL Country: Zip Code: 33125 Country(ies) of citizenship
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Box NOT Checked!

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1.

Country(ies) of citizenship: Country: Cuba

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(End of Country(ies) of citizenship List)

Type of document FS 240 or 545: { } Citizenship certificate: { } DS 1350: { } Naturalization certificate: { } Alien registration: { x } U.S. Passport: { } Other (Explain): { } Explanation
Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box NOT Checked! Box IS Checked! . Box NOT Checked! . Box NOT Checked! .

.

Field is blank!

Document number: A24430959 3.
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Relationship type: Brother Full name Last: Pinel First: Luis Middle: Javier Suffix: Deceased Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847
. . .

Field is blank!

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 Yes: { } No: { x } Date of birth Month/Day/Year: 07/22/1982 Place of birth City: Danli State: Country: Honduras Current address Street: 3116 NW 18 TR City: Miami State: FL Country: Zip Code: 33125 Country(ies) of citizenship
Box NOT Checked! . Box IS Checked! . . .

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1. 2.

Country(ies) of citizenship: Country: United States Country(ies) of citizenship: Country: Honduras
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(End of Country(ies) of citizenship List)

Type of document FS 240 or 545: { } Citizenship certificate: { } DS 1350: { } Naturalization certificate: { x } Alien registration: { } U.S. Passport: { } Other (Explain): { } Explanation
Box NOT Checked! . Box NOT Checked! . Box NOT Checked! . Box IS Checked! Box NOT Checked! . Box NOT Checked! . Box NOT Checked! .

.

Field is blank!

Document number: 30965658 4.
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Relationship type: Sister Full name Last: Aguiar First: Jazmine Middle: (NMN) Suffix: Deceased Yes: { } No: { x } Date of birth Month/Day/Year: 04/27/1988 Place of birth City: Miami State: FL Country: Current address Street: 3116 NW 18 TR City: Miami State: FL Country: Zip Code: 33125 Country(ies) of citizenship
. . . Box NOT Checked! . Box IS Checked! . . . .

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1.

Country(ies) of citizenship: Country: United States

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(End of Country(ies) of citizenship List)

Type of document FS 240 or 545: { } Citizenship certificate: { x } DS 1350: { } Naturalization certificate: { } Alien registration: { } U.S. Passport: { } Other (Explain): { } Explanation
Box NOT Checked! . Box IS Checked! . Box NOT Checked! . Box NOT Checked! Box NOT Checked! . Box NOT Checked! . Box NOT Checked! .

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Field is blank!

Document number: 10990048021

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Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

Page 17 of 24 Archival Copy

(End of List)

Section 19: Foreign Contacts
Do you have or have you had close and/or continuing contact with foreign nationals within the last 7 years with whom you, your spouse, or your cohabitant are bound by affection, influence, and/or obligation? Include associates, as well as relatives, not already listed in Section 18. (A foreign national is defined as any person who is not a citizen or national of the U.S.). Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Foreign Contacts (No Entry Provided)

Section 20: Foreign Activities
Respond for the time frame of the last 7 years.

Item 20A: Foreign Financial Interests
Include stocks, personal property, company shares, investments, or ownership of corporate entities. Exclude U.S.-based fund managers and accounts managed through your employer. 1. Do you have or have you EVER had any foreign financial businesses, foreign bank accounts, or other foreign financial interests of which you have direct control or direct ownership? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question 1, provide the type and amount of funds for each interest. Direct Foreign Financial Interests (No Entry Provided) 2. Do you have or have you had any foreign financial interests that someone controls on your behalf? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question 2, provide an entry for each interest. Exclude U.S.-based fund managers and accounts managed through your employer. Indirect Foreign Financial Interests (No Entry Provided) 3. Do you own or have you owned real estate in a foreign country? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question 3, provide an entry for each foreign real estate holding. Foreign Real Estate Holdings (No Entry Provided) 4. Do you receive or have you received any educational, medical, retirement, social welfare, or other such benefits from a foreign country? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question 4, provide an entry for each educational, medical, retirement, social welfare, or other such benefits from a foreign country. Foreign Benefits (No Entry Provided)

Section 20B: Foreign Business, Professional Activities, and Foreign Government Contacts
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PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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1. In the last 7 years, have you provided advice or support to anyone associated with a foreign business or other foreign organization that you have not previously listed as a former employer regarding any of the following: management, strategy, financing, or technology? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Was activity on official U.S. Government business? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If you answered "Yes" to question 1 AND the activity was outside of official U.S. Government business, provide entries to describe the advice/support provided. Advice/Support Activities (No Entry Provided) 2. In the last 7 years, have you attended any international conferences, trade shows, seminars, or other meetings outside of the U.S.? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Was activity on official U.S. Government business? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If you answered "Yes" to question 2 AND the activity was outside of official U.S. Government business, provide an entry for each event. Meetings (No Entry Provided) 3. In the last 7 years, have you or any of your immediate family members been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Was activity on official U.S. Government business? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If you answered "Yes" to question 3 AND the activity was outside of official U.S. Government business, provide an entry for each request/consultation. Requests/Consultations (No Entry Provided) 4. In the last 7 years, have you or any of your immediate family members had any contact with a foreign government, its establishment (embassies, consulates, agencies, or military services), or its representatives, whether inside or outside the U.S.? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Was activity on official U.S. Government business? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

Answer "No" if the contact was for routine visa applications and border crossings related to either official U.S. Government travel or foreign travel listed below in Question 20C. If contact was outside of official U.S. Government business, provide an entry for each contact. Government Contacts (No Entry Provided) 5. In the last 7 years, have you sponsored any foreign citizen to come to the U.S. as a student, for work, or for permanent residence? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

Page 19 of 24 Archival Copy

Was activity on official U.S. Government business? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If you answered "Yes" to question 5, provide an entry for each foreign citizen you sponsored. Sponsored Visits (No Entry Provided) 6. Have you EVER held or do you now hold a passport that was issued by a foreign government? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Was activity on official U.S. Government business? Yes: { } No: { }
Box NOT Checked! . Box NOT Checked! .

If you answered "Yes" to question 6, provide an entry for each foreign passport held. Foreign Passports (No Entry Provided)

Section 20C: Foreign Countries You Have Visited
Have you traveled outside the U.S. in the last 7 years? Respond for foreign countries you have visited in the last 7 years. Do not list travel under official U.S. Government business, but you must include any personal trips made in conjunction with the official U.S. Government travel. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

List foreign countries you have visited in the last 7 years. Foreign Travels (No Entry Provided)

Section 21: Mental and Emotional Health
Mental health counseling in and of itself is not a reason to revoke or deny a clearance. In the last 7 years, have you consulted with a health care professional regarding an emotional or mental health condition or were you hospitalized for such a condition? Answer "No" if the counseling was for any of the following reasons and was not court-ordered: • • strictly marital, family, grief not related to violence by you; or strictly related to adjustments from service in a military combat environment. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes," indicate who conducted the treatment and/or counseling, provide the following information, and sign the Authorization for Release of Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA). (No Entry Provided)

Section 22: Police Record
For this item, report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad. For questions a and b, respond for the timeframe of the last 7 years (if an SSBI go back 10 years). Exclude any fines of less than $300 for traffic offenses that do not involve alcohol or drugs. a. Have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you; are you on trial or awaiting a trial on criminal charges; or are you currently awaiting sentencing for a criminal Certified at 2011-04-12 19:52:55.330 PRIVACY ACT INFORMATION Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 offense? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked!

Page 20 of 24 Archival Copy

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b. Have you been arrested by any police officer, sheriff, marshal, or any other type of law enforcement officer? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

c. Have you EVER been charged with any felony offense? (Include those under Uniform Code of Military Justice.) Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

d. Have you EVER been charged with a firearms or explosives offense? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

e. Have you EVER been charged with any offense(s) related to alcohol or drugs? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to any question above, explain below, providing information for each and every offense. (No Entry Provided)

Section 23: Illegal Use of Drugs or Drug Activity
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information derived from your responses will be used as evidence against you in any subsequent criminal proceeding. a. In the last 7 years, have you illegally used any controlled substance, for example, cocaine, crack cocaine, THC (marijuana, hashish, etc.), narcotics (opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed, crystal methamphetamine, Ecstacy, ketamine, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants (toluene, amyl nitrate, etc.) or prescription drugs (including painkillers)? Use of a controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any controlled substance. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

b. Have you EVER illegally used a controlled substance while possessing a security clearance; while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

c. In the last 7 years, have you been involved in the illegal possession, purchase, manufacture, trafficking, production, transfer, shipping, receiving, handling, or sale of any controlled substance (see question a above) including prescription drugs? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

d. In the last 7 years, have you received counseling or treatment or have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of drugs? If you answered "Yes," provide date(s) of treatment and name(s) and address(es) of provider(s). You will be asked to sign an additional release if information is needed concerning any treatment. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to a - d above, provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity. (No Entry Provided)

Section 24: Use of Alcohol
Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

Page 21 of 24 Archival Copy

a. In the last 7 years, has your use of alcohol had a negative impact on your work performance, your professional or personal relationships, your finances, or resulted in intervention by law enforcement/public safety personnel? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question a, explain. Explanation
Field is blank!

b. In the last 7 years, have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

c. In the last 7 years, have you received counseling or treatment as a result of your use of alcohol? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question b or c above, provide the date(s) of treatment and the name(s) and address(es) of the counselor(s) or doctor(s) below. Do not repeat information reported in response to Section 21. You will be asked to sign an additional release if information is needed concerning any treatment. Treatments ( Information was provided in Section 21: { } ) (No Entry Provided)
Box NOT Checked! .

Section 25: Investigations and Clearance Record
a. Has the U.S. Government or a foreign government EVER investigated your background and/or granted you a security clearance? If "Yes," use the codes that follow to provide the requested information below. If "Yes," but you can't recall the investigating agency and/or the security clearance received, check "Unknown." If your response is "No," or you don't know or can't recall if you were investigated and cleared, check the "No" box. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question a, provide the requested information below. (No Entry Provided) b. To your knowledge, have you EVER had a clearance or access authorization denied, suspended, or revoked; or been debarred from government employment? If "Yes," give the action(s), date(s) of action(s), agency(ies), and circumstances. Note: An administrative downgrade or termination of a security clearance is not a revocation. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to question b, provide the requested information below. (No Entry Provided)

Section 26: Financial Record
For the following, answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including those for which you are a cosigner or guarantor. a. Have you filed a petition under any chapter of the bankruptcy code? If "Yes," indicate Chapter 7, 11, or 13. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

b. Have you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

c. Have you failed to pay Federal, state, or other taxes, or to file a tax return, when required by law or ordinance? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345 d. Have you had a lien placed against your property for failing to pay taxes or other debts? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Page 22 of 24 Archival Copy

e. Have you had a judgment entered against you? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

f. Have you defaulted on any type of loan? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

g. Have you had bills or debts turned over to a collection agency? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

h. Have you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

i. Have you been evicted for non-payment of financial obligations? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

j. Have you been delinquent on court-imposed alimony or child support payments? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

k. Have you had your wages, benefits, or assets garnished or attached for any reason? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

l. Have you been counseled, warned, or disciplined for violating terms of agreement for a travel or credit card provided by your employer? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

m. Have you been over 180 days delinquent on any debt(s)? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

n. Are you currently over 90 days delinquent on any debt(s)? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

o. Have you EVER experienced financial problems due to gambling? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

p. Are you currently delinquent on any Federal debt? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to any question above (a-p), provide the information requested below. For each "Yes" answer, provide the corresponding letters. Answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including those for which you are a cosigner or guarantor. (No Entry Provided)

Section 27: Use of Information Technology Systems
The following questions ask about your use of information technology systems. Information technology systems include all related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage, or protection of information. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information derived from your responses will be used as evidence against you in any subsequent criminal proceeding.

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

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a. In the last 7 years, have you illegally or without proper authorization entered into any information technology system? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

b. In the last 7 years, have you illegally or without authorization modified, destroyed, manipulated, or denied others access to information residing on an information technology system? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

c. In the last 7 years, have you introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to any question above (a-c), provide the following information. (No Entry Provided)

Section 28: Involvement in Non-Criminal Court Actions
In the last 7 years (if an SSBI go back 10 years), have you been a party to any public record civil court action(s) not listed elsewhere on this form? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes," provide the information about each public record civil court action(s). (No Entry Provided)

Section 29: Association Record
The following questions pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or coercion, or to affect the conduct of a government by mass destruction, assassination or kidnapping. a. Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to terrorism, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

b. Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to the use of violence or force to overthrow the U.S. Government, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

c. Have you EVER been an officer or a member of, or made a contribution to, an organization that unlawfully advocates or practices the commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the U.S. with the specific intent to further such unlawful activities? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

d. Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force with the specific intent to incite others to unlawful action in furtherance of such aims? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations Processing (e-QIP) Investigation Request #9991746 for Applicant SSN 589-98-3345

Page 24 of 24 Archival Copy

e. Have you EVER knowingly engaged in any activities designed to overthrow the U.S. Government by force? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

f. Have you EVER knowingly engaged in any acts of terrorism? Neither your truthful response nor information derived from your response to this question will be used as evidence against you in any subsequent criminal proceeding. Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

g. Have you EVER participated in militias (not including official state government militias) or paramilitary groups? Yes: { } No: { x }
Box NOT Checked! . Box IS Checked! .

If you answered "Yes" to any of the questions above, explain. Explanation
Field is blank!

Additional Comments
Use the space below to continue answers to all other items and to provide any information you would like to add. Before each answer, identify the number of the item. Additional Comments
Field is blank!

Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my security clearance, employment prospects, or job status, up to and including denial or revocation of my security clearance, or my removal and debarment from Federal service. Signature (Sign in ink) (Signature on file--see Investigation Request #9991746 Signature Forms) Date

Certified at 2011-04-12 19:52:55.330 Data Hash Code: 5faef73862fb1eebcffe2ee7f35b7fbed3c24847

PRIVACY ACT INFORMATION