Financial Disclosure Report
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3DEPARTMENT
OF HOMELAND SECURITY
U.S. Customs and Border Protection
PRIVACY ACT NOTICE FOR FINANCIAL DISCLOSURE REPORT
This information is
provided
pursuant
to
Pu blic
Law
93-579 (Privacy Act)
AUTHORITY
Executive Order
Number 10450,
as
amended,
reprinted
as
a Note
to
5 U.S.C. 7311; Executive Order
Number
12968;
5 Code of
Federal
Regulations
Parts
732,
736.
PURPOSES AND USES:
This
information
will
be used
in
national
security
investigations
to
ensure
that
employment,
and
continued
employment, of the
under-
signed
in
a
national
security position
is
consistent
with the
interests of the national
security. This
includes
use
of the
information
provid-
ed to determine
whether the
undersig
ned's
financial situation
furnishes reason to
believe
he
or she
may
be
subject
to
coercion,
influence,
or
pressure which
may
cause
him
or
her to
act
contrary
to
the best
interests
of
national
security.
The
financial
statement
is
closely
safeguarded
in
a
sealed
envelope to ensure
that
it
is
not
viewed
by unauthorized personnel.
However,
when
necessary
this information
may
be
furn
ished
to
authorized
persons for
purposes of granting/issuing a security
clearance
and
in
a criminal
investigation.
EFFECTS OF NONDISCLOSURE:
Disclosure
of
the
information
requested
is
voluntary.
However, in the
case of an applicant
for
a sensitive
position,
refusal to
comply
will
mean
that
the
fu
ll field
investigation
necessary
for occupancy
of that
position
cannot be
completed,
and
the
applicant
will
be
dropped
from consideration for employment
in that
position.
In
the case of an
employee
who
is
occupying a sensitive
position
pending comple-
tion
of
the
full
field
investigation,
refusal
to
comply
will mean
that
the
investigation
cannot be completed and
the
employee
will
be
reas-
signed
to
a
nonsensitive
position.
INSTRUCTIONS
The
information
contained
in the
attached
financial
disclosure
report
is
confidential.
Please
read the following instructions
carefully
before
preparing the
statement.
Please
print
plainly
or
type all answers.
Leave
no
space blank.
If
the
answer
is
"No"
or
"None"
so indicate
in the
space
provided.
2 Use additional
sheets
where
necessary.
Place
you
r name
and address at the
top
of each additional sheet. Identify
the
related
question
by
number.
All
additional sheets
should be
securely
attached
to
the
disclosure
report.
3
For the
purpose of
this
statement,
wherever
the term "immediate
family"
is
used,
it
means
spouse,
children or other
persons
dependent on
you,
or your
spouse,
for support.
4
Information required in
items
2a, 3a,
4a,
Sa, 6a,
7a,
8a,
9a,
10a
and
11
a
use
F
(filer);
S
(spouse);
D
(dependent) and 0 (other
individual
(s)).
5
Information
required
in
items
6b and 8b
use
V
(vehicle);
B (boat)
;
A (airplane) and
0 (other).
6
Information required in
item
1 Ob
use
2 (second
mortgage);
A
(auto);
E
(equity);
L
(line of
credit);
M
(mortgage)
;
0 (other
loan)
and
P
(personal).
7
Information required in
item
12a use
B
(bankruptcy);
G
(gift);
I
(inheritance);
S
(settlements);
T
(trust);
W
(winnings)
and
0
(other)
.
8 For
the
purpose of
this
statement,
information
required
in
Sections 2
through
12
apply not only
to
the applicant/employee
themselves,
but
to
any
fa
mily
member whereby the
applicant/employee has
access to
or
control
over such
assets, etc.
Only each
individual
asset,
valued in
excess of $1,000
is
to
be
listed. If the
asset
is
part of a group
(books, stamps,
etc.)
the
entire collection
,
if
valued
over
$1,000
shou ld
be
listed.
If assets
were
acquired by gift or
inheritance,
list
the approximate
fair
market
value,
when,
how,
and
from
whom
acquired
. Inheritances/gifts,
in
excess of
$5,000
are
to
be
reported
if
received w ithin the
past seven (7)
years.
9 liabilities
reflected
in
Section
11
can be approximate dollar amount owed. Account
numbers
are
not required
to be reflected,
however,
each account/creditor
is to
be identified
by name.
10
Upon
completion,
the financial
disclosure
report
shou
ld be
placed
In
a envelope, sealed and
returned
to
the
same official who
gave you the package
wh
ich
included the
blank form. A copy should be
retained for
your
records.
CBP
Form
258
(03/06)
1
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