20-10276a VBA Affiliate Background Investigation Request

OMB Control No. 2900-0915
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/20XX

VBA AFFILIATE BACKGROUND INVESTIGATION REQUEST

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on Page 2. Use this form to submit background
investigation requests. If you have questions about this request form, we can be reached by email at PersonnelSecurity.vbaco@va.gov.
SECTION I: APPLICANT INFORMATION (Completed by Applicant)
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and
completely fill in each applicable check box to help expedite processing of the form.
1. APPLICANT'S LEGAL NAME (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER

3. COUNTRY OF BIRTH

5. DATE OF BIRTH (MM/DD/YYYY)

6. CITIZENSHIP

4. CITY AND STATE OF BIRTH

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

8. NAME AND ADDRESS OF ASSIGNED DUTY STATION (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

9A. EMAIL ADDRESS (REQUIRED)

9B. TELEPHONE NUMBER

SECTION II: POSITION INFORMATION (Completed by VSOL)
10A. NAME OF VSO'S ORGANIZATION

10B. POSITION TITLE
12. ORGANIZATION POINT OF CONTACT (POC)

11. ACCREDITATION NUMBER

13. POC TELEPHONE NUMBER

14. POC EMAIL ADDRESS

SECTION III: VETERAN SERVICE ORGANIZATION LIAISON INFORMATION
15. NAME OF VSOL
16. VSOL REGIONAL OFFICE LOCATION
17. VSOL EMAIL ADDRESS

SECTION IV: TYPE OF BACKGROUND CHECK
18. SELECT TYPE

SECTION V: APPLICANT SELF CERTIFICATION OF CONTINUOUS SERVICE
19. Federal employment is defined as service in any branch of the United States military (Active, Guard, or Reserve), federal government civilian employment (any
federal government agency), or a contractor working for the federal government. I hereby certify my break in service from my last federal employment is indicated by
the block checked below.
I have NOT had a break in service. (Select one option)
My service was intra-agency (i.e., VA, VBA, VHA, NCA)
My service was inter-agency (other government agency, i.e., DOD, FBI, CIA, DOS, HHS, DHS, NSA, DOJ, NIH, etc.)
My break in service was less than 60 days.
My break in service was greater than 60 days, but less than two (2) years.
My break in service is greater than two (2) years OR I have never had federal employment as defined above.
20. SIGNATURE OF APPLICANT

VA FORM
XXX XXXX

20-10276a

21. DATE (MM/DD/YYYY)

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SECTION VI: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
22. SIGNATURE (REQUIRED)

23. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a
material fact you know to be false, or for fraudulent receipt of any document you are not entitled to.
PRIVACY ACT STATEMENT: VA is authorized to ask for the information requested on this form by Homeland Security Presidential Directive (HSPD)-12, and
31 USC 7701. The information and biometrics collected, collected as part of the Federal identity-proofing program under HSPD-12 are used to verify the personal
identity of VA applicants for employment, employees, contractors, and affiliates (such as students, WOC employees, and others) prior to issuing a Department
identification credential. The credentials themselves are to be used to authenticate electronic access requests from VA employees, contractors, and affiliates issued a
Department identification credential to gain access to VA facilities and networks (where available) through digital access control systems, as well as to other federal
government agency facilities and systems where permitted by law. The information collected on this form is protected by the Privacy Act, 5 USC Section 552(a)
and maintained under the authority of 38 USC Section 501 and 38 USC Sections 901-905 in VA system of records "Police and Security Records-VA (103VA07B)".
VA may make a "routine use" disclosure of the information in this system of records for the routine uses listed in this system of records, including civil or criminal
law enforcement, constituent congressional communications initiated at your request, litigation, or administrative proceedings in which the United States is a party
or has an interest, the administration of VA programs, verification of identity and status, and personnel administration by Federal agencies. Failure to provide all of
the requested information may result in VA being unable to process your request for a Personal Identity Verification Card, or denial of issuance of a Personal
Identity Verification Card. If you do not have a Personal Identity Verification Card, you may not be granted access to VA facilities or networks, which could have
an adverse impact on your application to become, or status as, a VA employee, contractor or affiliate where such access is required to perform your assigned duties
or responsibilities.
BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0915, and it expires XX/XX/20XX. Public reporting burden for this
collection of information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any
other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at
VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0915 in any correspondence. Do not send your completed VA Form 20-10276a to this
email address.

VA FORM 20-10276a, XXX XXXX

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