Ofi Form 86c - Special Agreement Check (Sac) - U.s. Office Of Personnel
ADVERTISEMENT
1
2
3SPECIAL AGREEMENT CHECK (SAC)
OFI FORM 86C
U.S. OFFICE OF PERSONNEL
MANAGEMENT
September 2001
Investigations Service
Agency
OPM
OPM Codes
Case Number
Agreement
USE
Number
ONLY
AGENCY USE ONLY (COMPLETE ITEMS 1 THROUGH 14 USING INSTRUCTIONS FROM THE BACK)
1.SUBJECT'S FULL NAME
2. DATE OF BIRTH
Last Name
First Name
Middle Name (Suffix)
Month
Day
Year
3. PLACE OF BIRTH (Use the two letter code for the State)
4. SOCIAL SECURITY NUMBER
City
County
State
Country
5. OTHER NAMES USED AND DATES WHEN USED
Name
From
To
Name
From
To
Month
Month
Month Year
Month Year
Year
Year
Name
From
To
Name
From
To
Month
Month
Month Year
Month Year
Year
Year
6.
SEX (Mark one box)
7.
SPECIAL AGREEMENT CODES
8.
POSITION TITLE
Female
A, D, H
Male
9. SON
10. SOI
12. Accounting Data
11. OPAC-ALC Number
M
2
1
0
2
C
13140001
8
1
13. OTHER INFORMATION REQUIRED BY AGREEMENT
Date of Prior Investigation: ______/______/__________
Type of Prior Investigation: [ ] SSBI
[ ] SSBI-PR [
] Other ____________
Month
Day
Year
(indicate type)
Please indicate relation code in block below and complete the necessary data.
20 - Spouse
21 - Cohabitant
(01) RELATION CODE __________
NAME:
LAST ___________________________________FIRST___________________________MIDDLE____________________SUFFIX__________
(eg: Jr., Sr., etc.)
Other Names Used
LAST
FIRST
MIDDLE
FROM (M/Y)
TO (M/Y)
NEE (X)
__________________________
________________________
_______________________
_____________
__________
_______
__________________________
________________________
_______________________
_____________
__________
_______
__________________________
________________________
_______________________
_____________
__________
_______
DOB ________/_____/__________ POB CITY_____________________________ STATE__________ COUNTRY___________________
SSN________-_______-__________ CITIZENSHIP
____________________________________________
CITIZENSHIP CERTIFICATION # ________________ DATE _____/____/______
CITY____________________________________STATE____________
ALIEN REGISTRATION #_________________________________ DATE _____/____/______
CITY______________________________________STATE_________
Date
Telephone Number
14.
Signature of Requesting Official
Name and Title of Requesting Official
(
)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Optional Form 612 - Optional Application For Federal Employment - U.s. Office Of Personnel Management
Legal
Form 201 - Request To Inspect Or Receive Copies Of Sf 278 Executive Branch Personnel Public Financial Disclosure Report Or Other Covered Record - U.s. Office Of Government Ethics - 1999
Legal
Form Hud-9746-a - Draw Request - U.s. Department Of Housing And Urban Development - Office Of Housing
Legal
Related Categories
Parent category: Legal