22019 PerSIST PIV Form

PIV & PRE-SECURITY FORM
U.S. Department of Housing and Urban Development
(For Federal Applicants, Contractors, PMFs, Volunteers, Interns)

PIV-HUD Form 22019
OMB control #2501-0038
Expiration Date xx-xx-xxxx

Return to HUD PIV Office, HQ Room 1101, 451 7th Street SW, Washington, DC 20410
SEPARATION DATE (MM/DD/YY):________ PIV CARD RETURN DATE (MM/DD/YY): ______________

Privacy Act Statement
Authority: Executive Orders: 10865, 12333, 12356, and 13764. Sections 3301 and 9101, of title 5, U.S. Code; section 2165 of title 42, U.S.
Code; sections 781 to 887 of title 50, U.S. Code; parts 5, 732, and 736 of title 5, Code of Federal Regulations; and Homeland Security
Presidential Directive (HSPD) 12, Policy for a Common Identification Standard for Federal Employees and Contractors, August 21, 2004.
Executive Order 13488, and Executive Order 13467.
Principal Purpose: Records in the system are used to document and support decisions regarding the suitability, eligibility, and fitness for
services of applicants for federal employment and contract positions to include students, interns, or volunteers to the extent that their duties
require access to federal facilities, information, systems, or applications. Additionally, records may be used to document security violations,
and supervisory actions taken.
Routine Use: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) and to appropriate agencies, entities, and persons
for disclosures compatible with the purpose for which the records in this system were collected as set forth by Appendix I — HUD's Routine
Use Inventory Notice, 80 FR 81837 (December 31, 2015), all or a portion of the records or information contained in this system may be
disclosed outside HUD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: (Please see System of Record Notice (SORN) for
complete list)
Disclosure: Voluntary; however failure to submit this information may result in employment denial.
SORN ID: https://www.gpo.gov/fdsys/pkg/FR-2018-05-11/pdf/2018-10103.pdf (Personnel Security Integrated System for Tracking
(PerSIST); P315
STATEMENT OF BURDEN: Public reporting burden for this collection of information is estimated to average .17 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
HUD collects this information to comply with the requirements outlined in Homeland Security Presidential Directive (HSPD-12), the Federal
Information Processing Standard (FIPS) 201-2, and OMB Memorandums M-05-24 and the M-19-17, which assert that all governmental
agencies must implement a secure identity proofing, registration, and issuance process for identity verification, prior to granting federal and
non-federal employee’s access to federally controlled facilities and/or information systems. The information being collected will be used for
processing requests for Personal Identity Verification (PIV) credentials (ID Badges) for Federal employees and Federal contractors. This
information is required for access to federally controlled facilities and information systems pursuant to HSPD-12. If this information is not
provided, HUD will not be able to complete their identity proofing and registration process. The information being collected is protected
pursuant to the Privacy Act (5 U.S.C.§ 552a).

PIV & PRE-SECURITY FORM
U.S. Department of Housing and Urban Development
(For Federal Applicants, Contractors, PMFs, Volunteers, Interns)

PIV-HUD Form 22019
OMB control #2501-0038
Expiration Date xx-xx-xxxx

PIV & PRE-SECURITY FORM
U.S. Department of Housing and Urban Development
(For Federal Applicants, Contractors, PMFs, Volunteers, Interns)
FEDERAL ☐

CONTRACTOR☐ (Change)

PMF☐

VOLUNTEER☐

INTERN☐

APPLICANT INFORMATION:
LAST NAME: _________________

FIRST NAME: _____________

POSITION TITLE: _____________ SOCIAL SECURITY NUMBER (SSN):

____

MIDDLE NAME: _________________

- -

DATE of BIRTH (MM/DD/YY): ____/ /_______
RESIDENCE ADDRESS: _______________________ CITY: ____________ STATE: _____ ZIP CODE: ____________
HOME PHONE: ( ) ___________ ALTERNATE #: ( )_____________ E-MAIL ADDRESS:______________________
PLACE of BIRTH (POB): ___________________ Are you a U.S. CITIZEN?

☐Yes

☐No

If no, COUNTRY of CITIZENSHIP:
NATURALIZATION CERTIFICATE # ______________
(Country, if non-US) __________________ (City) _________ (State) _______________ If Applicable

SPONSOR INFORMATION: (For Federal Onboarding ONLY)
LAST NAME: _____________ FIRST NAME: _______________ PHONE NUMBER: ( ) ______________ Ext. _____
PROGRAM OFFICE/DIVISION: ___________ LOCATION: __________ ROOM#: _________DOMAIN: ________
ADMINISTRATIVE OFFICER: LAST NAME: __________ FIRST NAME: ___________ PHONE NUMBER: ( ) __________

NOT TO EXCEED DATE (MM/DD/YYYY): _________________

COR and CONTRACT INFORMATION: (For Contractor Onboarding ONLY)
LAST NAME: _____________ FIRST NAME: ______________ PHONE NUMBER: ( ) ______________ Ext. _____
PROGRAM OFFICE/DIVISION: ___________ LOCATION: __________ ROOM#: _________ DOMAIN: ______
VENDOR NAME: _____________________ CONTRACT NUMBER: ___________________________________
CONTRACT EXPIRATION DATE (MM/DD/YYYY): _______________________________
WILL CONTRACTOR NEED LAN ACCESS?

☐YES

☐NO

WILL CONTRACTOR NEED HUD PIV CARD?

☐YES

☐NO

PIV CARD: __________________________________