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26080901
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Personnel Action Forms
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26080901
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Personnel Action Forms
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Records of the First Lady's Office (Clinton Administration)
Margaret “Maggie” Williams' Subject Files
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Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. form
The White House Change in Employee Status [Sara Grote] (partial) (1
n.d.
b(6)
page)
002. form
The White House Separation Action [Diane Limo] (partial) (1 page)
09/28/94
b(6)
003. form
The White House Pre-Employment Information [Eric Hothem]
n.d.
b(6)
(partial) (1 page)
004. form
The White House Pre-Employment Information [Evan Ryan] (partial)
n.d.
b(6)
(1 page)
005. form
White House Office Supplemental Information Sheet for Personnel
n.d.
b(6)
Action (1 page)
006. form
Appointment Subject to Drug Testing (1 page)
n.d.
b(6)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry1508
RESTRICTION CODES
Presidential Records Act - 144 U.S.C. 2204(a)]
Freedom of Information Act - 15 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA|
b(1) National security classified information |(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA|
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute [(a)(3) of the PRA
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information |(a)(4) of the PRA
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors |a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions |(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
FIRST LADY'S OFFICE
MAGGIE WILLIAMS
EVAN RYAN
Folders to be Archived
(Recorded by Folder Name)
Box 2 of 2: 2
From Drawer 2:
Personnel Action Forms
Receipts
Records Management
State Arrival
Telephone Etiquette
Travel -
WHITE HOUSE TRAVEL OFFICE REPORT
Whitewater
TRAVELBUDGET
ENCLOSURES FILED OVERSIZE ATTACHMENTS 12746
/ boxfiled 10/21/9805
NARA 10209
TRANSITION
WHITE HOUSE STAFF REFERRAL / SPONSORSHIP
Please complete this form for individuals who contact you regarding appointments to jobs in the
Administration. This will help the Office of Presidential Personnel respond to applicants in a prompt and
professional manner. Please attach a copy of this sheet for each applicant's resume that you send to us.
Date:
Name of Applicant:
Address:
Office Phone:
Home Phone:
Fax:
Level or Type of Appointment Desired or Appropriate:
PAS
PA
SES
Schedule C
Unknown
Part-time Board or Commission
Full-time Job
Areas of Interest:
1.
4.
2.
5.
3.
6.
Please Check if Appropriate:
I want to be a sponsor for this person
I am simply referring this resume to your office
Please acknowledge my referral by letter to the applicant
Special Notes:
Your Name (Print):
Office:
Office Extension:
Signature:
Please submit with resumes to the Office of Presidential Personnel, OEOB Room 153.
TRANSITION
WHITE HOUSE STAFF REFERRAL / SPONSORSHIP
Please complete this form for individuals who contact you regarding appointments to jobs in the
Administration. This will help the Office of Presidential Personnel respond to applicants in a prompt and
professional manner. Please attach a copy of this sheet for each applicant's resume that you send to us.
Date:
Name of Applicant:
Address:
Office Phone:
Home Phone:
Fax:
Level or Type of Appointment Desired or Appropriate:
PAS
PA
SES
Schedule C
Unknown
Part-time Board or Commission
Full-time Job
Areas of Interest:
1.
4.
2.
5.
3.
6.
Please Check if Appropriate:
I want to be a sponsor for this person
I am simply referring this resume to your office
Please acknowledge my referral by letter to the applicant
Special Notes:
Your Name (Print):
Office:
Office Extension:
Signature:
Please submit with resumes to the Office of Presidential Personnel, OEOB Room 153.
TRANSITION
WHITE HOUSE STAFF REFERRAL / SPONSORSHIP
Please complete this form for individuals who contact you regarding appointments to jobs in the
Administration. This will help the Office of Presidential Personnel respond to applicants in a prompt and
professional manner. Please attach a copy of this sheet for each applicant's resume that you send to us.
Date:
Name of Applicant:
Address:
Office Phone:
Home Phone:
Fax:
Level or Type of Appointment Desired or Appropriate:
PAS
PA
SES
Schedule C
Unknown
Part-time Board or Commission
Full-time Job
Areas of Interest:
1.
4.
2.
5.
3.
6.
Please Check if Appropriate:
I want to be a sponsor for this person
I am simply referring this resume to your office
Please acknowledge my referral by letter to the applicant
Special Notes:
Your Name (Print):
Office:
Office Extension:
Signature:
Please submit with resumes to the Office of Presidential Personnel, OEOB Room 153.
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Pre-Employment Inquires:
Avoiding Discrimination
EEO.
Pre-Employment Inquires:
Avoiding Discrimination
A Guide for Managers
and Supervisors
EEO
EQUAL EMPLOYMENT OPPORTUNITY
O
o
Office of Administration
Equal Employment Opportunity
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Pre- Employment Inquires: Avaiding
Discrimination
EEO
Pre-Employment Inquires:
Avoiding Discrimination
A Guide for Managers
and Supervisors
EEO
EQUAL EMPLOYMENT OPPORTUNITY
00000000
Office of Administration
Equal Employment Opportunity
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. form
The White House Change in Employee Status [Sara Grote] (partial) (1
n.d.
b(6)
page)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry1508
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - 15 U.S.C. 552(b)]
PI National Security Classified Information |(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office |(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRAJ
an agency |(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute |(b)(3) of the FOIA|
financial information |(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors |a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(b)(6) of the FOIA]
personal privacy |(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions |(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells |(b)(9) of the FOIA|
RR. Document will be reviewed upon request.
The White House
Change in Employee Status
To be completed by requesting office
Section I: Complete all data
Name of Employee: Grote
Sara
Chase
[001]
Last
First
Middle
Social Security Number:
(b)(6)
Office/Department/Agency:
office of Scheduling Advance
Section II: Check the Appropriate Box(es):
Reassignment within the White House Office (complete Section III below)
Change in title
Change in salary (complete Section III below)
Change in work schedule (complete Section III below)
Extension of temporary appointment (enter new ending date below)
Change in category (complete Section III below)
Other:
Section III: Complete all sections as appropriate
New Position Title: Deputy Director of Scheduling Requested
by:
fr the FL
Current Salary:
28,000
New Salary: 30,000
Proposed effective date of change:
8-11-95
Ending date:
Work Schedule (circle new schedule)
Full Time
Part Time
Intermittent
Category (circle new category)
Permanent
Temporary
New ending date
Approvals:
Assistant www to the President
Office of Management & Administration
9-5-95
Date
Date
Upon approval or disapproval please return to:
Patti Solis
185.5
67560
Name
Room
Extension
Revised 3/94
The White House
Change in Employee Status
To be completed by requesting office
Section I: Complete all data
Name of Employee:
Corlette, Sabrina
Last
First
Middle
Social Security Number:
Office/Department/Agency: Office OF the First Lady
Section II: Check the Appropriate Box(es):
Reassignment within the White House Office (complete Section III below)
Change in title
Change in salary (complete Section III below)
Change in work schedule (complete Section III below)
Extension of temporary appointment (enter new ending date below)
Change in category (complete Section III below)
Other:
Section III: Complete all sections as appropriate
New Position Title:
Requested by: Maggie Williams
Current Salary:
New Salary:
Proposed effective date of change:
7/31/95
Ending date:
8/31/95
Work Schedule (circle new schedule)
Full Time
Part Time
Intermittent
Category (circle new category)
Permanent
Temporary
New ending date 8/31/95
Approvals:
Margard Assistantito the President 7/27/95 askiliams
Office of Management & Administration
Date
Date
Upon approval or disapproval please return to:
Evan Ryan
100 DEOB
x66266
Name
Room
Extension
Revised 3/94
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
002. form
The White House Separation Action [Diane Limo] (partial) (1 page)
09/28/94
b(6)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry1508
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - 15 U.S.C. 552(b)]
P1 National Security Classified Information |(a)(1) of the PRA|
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office |(a)(2) of the PRAJ
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information |(a)(4) of the PRA|
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy |(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
Sert afo SF.P
? 28 8 1994
The White House
Separation Action
Name of Employee: Limo
Diane
Gloria- Jean
Last
First
Middle
[002]
(b)(6)
Social Security Number:
Office/Department/Agency White House office/Office of the first Lady
Check the Appropriate Action:
Resignation (state reason below)
Transfer to another government agency (indicate agency) OMB
Retirement
Effective Date: September 26,1994
Signature of Departing Employee: Siane Lino
Forwarding Address:
Office of Management and Budget
Old Executive Office Bldg.
Room 262
Telephone Number:
(202) 395 - 9153
Reason for
Resignation: Transfer 40 another agency
Cofc. of management and Budget)
(Healthcare & Veteran's Affairs Division)
Revised 1/94
THE WHITE HOUSE
EMPLOYEE CHECK-OUT
Name:
First
Last
Instructions
Diane
Limo
In an effort to expedite the check-out
Date of Separation:
Month
Day
Year
process, the offices have been arranged in
order from the 5th floor of the OEOB down
Sept.
23
1994
to and including the basement.
Current Mailing Address:
Upon completion of this form, your signature
The white House
Ofc. of the first. Lady
is required as verification of accuracy.
OEOB Room 100
Any questions regarding this procedure
Forwarding Address:
should be referred to the White House
The white House
Personnel Liaison x6-2014.
Ofc OEOB of Management and Budget
Room 262
PLEASE NOTE: Your final paycheck cannot be issued until this form has been completed in full
and returned to the White House Personnel Liaison.
1. Equipment has been returned to the White House Communications Agency.
White House
Donald P. Va Drin
Communications Agency
OEOB, Room 444 (Ext. 7-1234)
23 SEP 94
2. White House Mess has been paid and White House Mess privileges cancelled.
White House Staff Mess
OEOB, Room 404 (Ext. 5-4192)
wind 9/23/94
3. Library materials charged to the employee have been returned.
White House Library
OEOB, Room 308 (Ext. 5-7000)
martha B Schiele
9/23/94
4. Financial disclosure termination report has been filed.
White House Counsel's Office
OEOB, Room 128 (Ext. 6-7900)
N/A Kataleen 711 Whalen 9/29/94
White House Mail Room
5. White House 8 Mail Room has been advised of a forwarding address.
OEOB, Room 49 (Ext. 5-2542)
9/23/94
6. White House Federal Credit Union has been advised of a forwarding address.
White House Credit Union
Patri G. Pinlod
OEOB, Room 42 (Ext. 6-2900)
9/23/94
7. Official or Diplomatic Passport has been returned to the White House Travel Office.
White House Travel Office
OEOB, Room 87 (Ext. 6-2250)
9/23/94
8. Deposit of Presidential Papers and oral history have been completed.
White House Records Management
OEOB, Room 80 (Ext. 6-2240)
Everlene H. Fisher
9/23/94
Continued on Reverse
PHOTOCOPY
Revised May 1994
PRESERVATION
9. Parking requirements have been satisfied.
White House Administrative Office
OEOB, Room 1 (Ext. 6-2500)
E. R. Ublum
9/23/94
10. Outstanding travel advances have been paid.
White House Administrative Office
N/A Oren Burland 9/23/911
OEOB, Room 1 (Ext. 6-2500)
11. Senior Staff Gym key has been returned.
White House Administrative Office
N/A Chair Husbard 9/23/94
OEOB, Room 1 (Ext. 6-2500)
12. White House Telephone Switchboard has been advised of a forwarding telephone number.
White House Telephone Service
OEOB, Room 09 (Ext. 6-2134)
9/23/99
13. Any outstanding White House Athletic Center fees have been paid and WHAC membership
White House Athletic Center
cancelled.
DEOB, Room 2008 (Ext. 5-5688)
9/20/94
14. Office of Administration/Information Systems and Technology Division -
Client Services Desk
NEOB, Room 5233 (Ext. 5-7370)
Ximbals Have I.D. Password and Account Number been deactivated? 9/29/94
15. Security debriefing has completed.
White House Security Office
OEOB, Room 84 (Ext. 6-2345)
Lsa sweD 9/29/94
16. Employee's Staff Pin has been returned to the Secret/Service.
Presidential Protection Division
USSS
OEOB, Room 10 (Ext. 5-4112)
VA White Milmane House, EOB Vol. Pass, USSS Keys,
9-23-94
17. Employee's or Commission Book, have been
Technical Security Division, USSS
returned to Secret Service.
OEOB, Room 23 (Ext. 5-4259)
Not reta, Keys Returned
Ms 9-29-94
18. Provide address for final check; check this form for completion and ensure that necessary forms
White House Personnel Liaison
OEOB, Room 145 (Ext. 6-2014)
and sonnel actions have been completed. U.Clure 9/23/96/
I certify that procedures for separation have been satisfied to the best of my knowledge and belief.
Signature Diane Line
Date 9/23/94
REMEMBER, YOUR FINAL PAYCHECK AND/OR LUMP SUM LEAVE PAYMENT CANNOT BE ISSUED UNTIL YOU HAVE
COMPLETED THIS FORM AND RETURNED IT TO THE WHITE HOUSE PERSONNEL LIAISON.
PHOTOCOPY
PRESERVATION
THE WHITE HOUSE
EMPLOYEE CHECK-OUT ADDENDUM
Name:
First
Last
Diane
Limo
Instructions
Date of Separation:
Month
Day
Year
White House Airlift Operations has
been added to the Check Out procedure
Sept.
23,
1994
for all White House employees. Please
Current Mailing Address:
The white House
be certain to stop at their office in Room
Otc. OGOB of the First Lady
405 after you complete your check out
Room 100
with the White House Staff Mess.
Forwarding Address:
The white House
Ofc. of THE Management and Budget
OEOB Room. 262
PLEASE NOTE: Your final paycheck cannot be issued until this form has been completed in full
and returned to the White House Personnel Liaison.
2a. White House Airlift Operations invoices have been paid.
White House Airlift Operations
OEOB, Room 405 (Ext. 5-2006)
940423 JSG H:11 John
PHOTOCOPY
PRESERVATION
THE PREMIENTO PATION 1 CENTER
EXECUTIVE OFFICE OF THE PRESIDENT
OFFICE OF ADMINISTRATION
Washington, D.C. 20503
September 9, 1994
MEMORANDUM FOR ADMINISTRATIVE CONTACTS
FROM:
JOHN DEPUTY W. DIRECTOR CRESSMAN Seen
SUBJECT:
EOP Telephone Directory
We would like to give each of you a final opportunity to review your section of the telephone
directory and make any changes that have occured since our last update request. Please note
that only EOP staff should be included in the telephone directory and listed once.
You will notice that we have structurally improved each section by alphabetizing the
divisions and offering an organization number for each division and subdivision. Please
review your section carefully for correct phone numbers (i.e. division, subdivision and direct
numbers for the appropriate staff).
Please forward a signed copy of this memorandum and your changes to Ashley Raines,
x62023, OEOB 145 by. 12:00 noon on Tuesday, September 13, 1994.
Thank you for your assistance.
Attachments
cc:
Patsy Thomasson
Please check one:
Approved with no changes
Approved with the changes indicated
Siane Limo
9.19.94
Signature
Date
PHOTOCOPY
PRESERVATION
FELLOWSHIPS, WHITE HOUSE
395-4522
Director
Shearer. Brooke
395-4522
Fax 395-6179
712 Jackson Pl.
Associate Director
Shiffman. John
395-4522
"
"
"
712 Jackson Pl.
Administrative Officer
Kelliher, Janet
395-7473
"
H
"
712 Jackson Pl.
Special Assistant
Wechsler. William
395-7475
"
#
#
712 Jackson Pl.
Management Analyst
Holmes, Patricia
395-7471
"
"
"
712 Jackson Pl.
Education Assistant
Sanders, Roberta
395-7470
"
"
"
712 Jackson Pl.
Staff Assistant
Johnson. Margaret
395-7472
"
"
"
712 Jackson Pl.
FIRST LADY
456-6266
The First Lady
Clinton, Hillary Rodham
456-6266
Fax 456-6244
2FL/WW
WH
Assistant to the President and Chief of
Staff to the First Lady
Williams, Margaret A.
456-6266
"
"
"
2FL/WW
WH
Assistant to the Chief of Staff to the
First Lady
Lieberman, Evelyn S.
456-6266
"
"
#
100
OEOB
Deputy Assistant to the President and
Deputy Chief of Staff to the First
Lady
Verveer. Melanne
456-6266
"
"
"
100
OEOB
Special AssistantOffice Manager
Limo, Diane G. EVAN RYAN
456-6751-
"
"
"
100
OEOB
Deputy Assistant to the President and
6266
Press Secretary to the First Lady
Caputo, Lisa
456-2960
Fax 456-7805
100
OEOB
Deputy Press Secretary to the First
Lady
Lattimore, Neel
456-2960
"
"
"
100
OEOB
Deputy Press Secretary to the First
Lady
Finney, Karen
456-2960
"
"
"
100
OEOB
Special Assistant to the First Lady
Marshall. Capricia P.
456-7064
Fax 456-6235
2FL/EW
WH
Special Assistant to the President and
Social Secretary
Stock. Ann
456-7136
"
"
"
2FL/EW
WH
Deputy Social Secretary
Dickey, Robyn
456-7462
"
"
"
2FL/EW
WH
Special Assistant to the Social
Secretary
Donnett. Joyce
Trac ey LeBrecht
456-6303
"
"
"
1FL/EW
WH
Assistant to the Social Secretary
Dickey, Helen
456-7707
"
"
"
2FL/EW
WH
Director, First Lady's
Correspondence
Pushkar. Alice
456-5955
Fax 456-2806
18
OEOB
GENERAL COUNSEL
Special Counsel to the President
Cutler. Lloyd
456-2632
Fax 456-6279
2FL/WW
WH
Deputy Counsel to the President
Klein, Joel I.
456-6611
"
"
"
2FL/WW
WH
Executive Assistant
Poole, Cheryl
456-2632
"
"
"
2FL/WW
WH
Executive Assistant
Mixell, Julie
456-6611
"
"
"
2FL/WW
WH
Staff Assistant
Willey, Kathleen
456-6611
"
"
"
2FL/WW
WH
Associate Counsel to the President
Eggleston. Neil W.
456-7901
Fax 456-1647
125
OEOB
Associate Counsel to the President
Kennedy. William H.
456-6229
Fax 456-2146
136
OEOB
Associate Counsel to the President
Mills, Cheryl D.
456-7900
Fax 456-1647
128
OEOB
Associate Counsel to the President
Neuwirth. Stephen R.
456-7903
"
"
"
130
OEOB
Associate Counsel to the President
Nolan, Beth
456-6229
Fax 456-2146
136
OEOB
Associate Counsel to the President
Radd. Victoria L.
456-7901
Fax 456-1647
125
OEOB
Associate Counsel to the President
Sloan, Clifford M.
456-7900
"
"
"
128
OEOB
Assistant Counsel to the President
Cerda, Clarissa
456-7903
"
"
"
128
OEOB
Assistant Counsel to the President
Krislov. Marvin
456-7903
"
"
"
128
OEOB
Assistant Counsel to the President
Whalen, Kathleen M.
456-7900
=
"
"
126.5
OEOB
Executive Assistant
Pond, Betsy L.
456-6229
Fax 456-2146
136
OEOB
Staff Assistant
Castleton. Thomas E.
456-6229
"
"
"
140
OEOB
Staff Assistant
Champagne. Florence
456-7900
Fax 456-1647
128
OEOB
Paralegal
Mauton. Clifford
456-6229
Fax 456-2146
140
OEOB
WHO-4
09/09/94
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
003. form
The White House Pre-Employment Information [Eric Hothem]
n.d.
b(6)
(partial) (1 page)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry1508
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P1 National Security Classified Information |(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information [(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information |(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA|
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy |(a)(6) of the PRA|
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
THE WHITE HOUSE
PRE-EMPLOYMENT INFORMATION
exiended Kelly we 12/15
3>
Name: Hothem
Eric
P.
Last
First
Middle Initial
SSN:
(b)(6)
[003]
Local Address:
805 N. Howard Street, #325 Alexandria, VA
22304
Street
City
State
Zip
Phone:
(703) 823-8741
(202) 456-6266
Home
Work
Department:
Office of the First Lady
Requested By:
Margaret Williams
Position Title: Data Entry Clerk
Salary: $32,000
Proposed Date of Employment:
11/22/93
Ending Date, (If Possible)
12/31/93
Work Schedule (circle one):
Full Time
Part Time
Intermittent
APPROVALS
Assistant to the President
Office of Management and Administration
Nov. 11, 1993
Date
Date
Upon approval or disapproval, return to:
Diane G. Limo
100-OEOB
x6266
Name
Room
Ext.
ROOM NUMBER
OCCUPANT (S)
TITLE
OFFICE OF THE FIRST LADY
100A
First Lady's Conference Room
100B
Diane Limo
Office Manager/
Special Assistant
Reception Area
Christie Carter
Intern (M-F)
Ayanna Dunn
Intern (M-F)
Bethany Hopkins
Intern (M-F)
Evan Ryan
Intern (M-F)
Stepheney Keyser
Volunteer (M,T)
Phyllis Hannum
Volunteer (M)
Marie White
Volunteer (M)
E. Marie Johnson
Volunteer (M,T)
Elli Klein
Volunteer (M,W,F)
Phyllis Scribner
Volunteer (T)
Muriel Alper
Volunteer (T,W)
Estabania Lastra
Volunteer (T,TH)
Nancy Pittman
Volunteer (W)
Yona McNish
Volunteer (W)
Miriam Leverage
Volunteer (TH)
Eloise Buford
Volunteer (F)
E. Betty Wright
Volunteer (F)
Marjory Goldman
Volunteer (TH)
Allison Martin
Volunteer (T)
100C
Maggie Williams
Chief of Staff
to the First
Lady
Evelyn Lieberman
Executive
Assistant
101
Melanne Verveer
Deputy Chief of
Staff to the
First Lady
Anne Bartley
Permanent
Volunteer-
Assistant to the
Chief of Staff to
the First Lady
102
Nicole Rabner
Intern (M-F)
Katy Button
Intern (M-F)
Iris Evenson
Intern (M-F)
Madge Henning
Volunteer (M,W,F)
LouAnne Nyberg
Intern (M-F)
102
Barbara Zelenko
Volunteer (T, TH)
Jean Johnson
Volunteer (as
needed)
103
Neel Lattimore
Deputy Press
Secretary to the
First Lady
Karen Finney
Deputy Press
Secretary to the
First Lady
Laurie Robinson
Intern (M-F)
Tonya Smith
Intern (M-F)
104
Lisa Caputo
Deputy Assistant
to the President
and Press
Secretary to the
First Lady
OEOB/WH 1st Floor Staff 3/11/94
12 Today Rm. 145
ROOM NUMBER
OCCUPANT(S)
TITLE
OFFICE OF THE FIRST LADY
100A
First Lady's Conference Room
100B
Diane Limo
Office Manager/Special
Assistant
Reception area
Adaobi Okobi Christy carter
Intern (M,W,F) (M-F)
Evan Ryan
Intern (M-F)
Stephney Keyser
Volunteer (M,T)
Ayana Dunn Inten (M-F)
Phyllis Hannum
Volunteer (M)
Bethany Hopkins Intern (M-F)
Marie White
Volunteer (M)
E. Marie Johnson
Volunteer (M,T)
Elli Klein
Volunteer (M,W,F)
Phyllis Fineschriber
Volunteer (T)
Muriel Alper
Volunteer (T,W)
Estabania Lastra
Volunteer (T, TH)
Nancy Pittman
Volunteer (W)
Yona McNish
Volunteer (W)
Dionne Reeder
Volunteer (W)
Miriam Leverage
Volunteer (TH)
Eloise Buford
Volunteer (F)
E. Betty Wright
Volunteer (F)
Marjory Goldman
Volunteer (TH)
Allison Martin
Volunteer (F) (T)
100C
Maggie Williams
Chief of Staff to the First
Lady
Evelyn Lieberman
Executive Assistant
101
Melanne Verveer
Deputy Chief of Staff to the
First Lady
Anne Bartley
Permanent Volunter -
Assistant to the Chief of
Staff to the First Lady
102
Nicole Rabner
Intern (M-F)
Katy Button
Intern (M,W,F) (M-F)
JoAnne Richards Ir is Evenson
Intern (M-F)
Madge Henning
Volunteer (M,W,F)
LouAnn nyberg
Intern Intern(M-F) (M-F)
1
OEOB/WH 1st Floor Staff 3/11/94
102
Barbara Zelenko
Volunteer (T,TH)
Jean Johnson
Volunteer (as needed)
103
Neel Lattimore
Deputy Press Secretary to
the First Lady
Karen Finney
Deputy Press Secretary to
Laurie Robinson
the First Lady
Heidi Kranz
Intern (MWF) (M-F)
Elizabeth Whitmer
Intern (M-F)
Tonya Smith
104
Lisa Caputo
Deputy Assistant to the
President and Press
Secretary to the First Lady
OFFICE OF INTERGOVERNMENTAL AFFAIRS
106
John Hart
Deputy Assistant to the
President and Deputy
Director of
Intergovernmental Affairs
Keith Mason
Deputy Assistant to the
President and Deputy
Director of
Intergovernmental Affairs
Loretta T. Avent
Special Assistant to the
President for
Intergovernmental Affairs
Elise Deal
Executive Assistant
Elizabeth Spencer
Executive Assistant
Anna Erdreich
Intern for John Hart
Christopher Day
Intern
Lawton Jordon
Volunteer/Intern for Keith
Mason
110
Sharon Kennedy
Executive Assistant
Patrice Stanely
intern for Sharon Kennedy
WHITE HOUSE MEDICAL UNIT
105-107
1 - Doctors
2 - Physicians' Assistants
3 - Corpsmen or nurses
2
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
004. form
The White House Pre-Employment Information [Evan Ryan] (partial)
n.d.
b(6)
(1 page)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry 1508
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - 15 U.S.C. 552(b)]
P1 National Security Classified Information |(a)(1) of the PRA
b(1) National security classified information |(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office |(a)(2) of the PRA
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information |(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors |a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIAJ
personal privacy |(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
THE WHITE HOUSE
PRE-EMPLOYMENT INFORMATION
[004]
Name:
Ryan
Evan
M
Last
First
Middle Initial
SSN:
(b)(6)
Local Address:
478 Naylor Pl.
Alexandria, VA
22304
Street
City
State
Zip
Phone:
703-751-3937
202-456-6266
Home
Work
Department: WHO/Office of the First Lad Requested By: Maggie Williams
Position Title:
Office Manager
Salary:
$25,500
Proposed Date of Employment:
9/26/94
Ending Date, (If Possible)
Work Schedule (circle one):
Full Time
Part Time
Intermittent
APPROVALS
Margard Assistant to the
astile President
Office of Management and Administration
9/20/94
Date
Date
Upon approval or disapproval, return to:
Diane Limo
Room 100 OEOB
x66266
Name
Room
Ext.
PHOTOCOPY
PRESERVATION
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
005. form
White House Office Supplemental Information Sheet for Personnel
n.d.
b(6)
Action (1 page)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry1508
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - (5 U.S.C. 552(b)|
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA
an agency |(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute |(b)(3) of the FOIA]
financial information |(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
006. form
Appointment Subject to Drug Testing (1 page)
n.d.
b(6)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Maggie Williams (Subject Files)
OA/Box Number: 12746
FOLDER TITLE:
Personnel Action Forms
2013-0359-S
ry1508
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute [(a)(3) of the PRA|
an agency |(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information [(a)(4) of the PRA
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA|
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA|
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions |(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
THE WHITE HOUSE
WASHINGTON
MEMORANDUM
TO: WHITE HOUSE OFFICE STAFF
FR: BERNARD NUSSBAUM
COUNSEL TO THE PRESIDENT
Before a final decision on your employment can be made, certain
background investigations and conflict-of-interest reviews must
be completed. Accordingly, I am providing you with the enclosed
package of security clearance forms and questionnaires for your
completion. The FBI cannot begin its full-field investigation
until we receive your typed, completed and signed forms.
Completed packages should consist of:
Item
Number We Need
1. Questionnaire for
One original and THREE
Sensitive Positions
copies, all with original
(SF 86) plus any
signatures. NOTE: the
attachments
SF 86 requires two signatures
2. Consent Memorandum from
One Original and one copy,
Bernard Nussbaum
both with original signatures
3. Tax Check Waiver
TWO signed originals
THESE FORMS MUST BE TYPED
COMPLETED, EXECUTED, AND RETURNED AS SOON AS
POSSIBLE (PREFERABLLY WITHIN 3 DAYS) TO MR. CRAIG
LIVINGSTONE, DIRECTOR, WHITE HOUSE SECURITY
PERSONNEL SECURITY OFFICE, (OEOB, ROOM 84)
4.
Personal Data Statement
Original. This Questionnaire
only is to be returned to
Mr. Edgar Bueno, Office of
Counsel to the President,
Room 136, OEOB.
For information about financial disclosure, please see
enclosed sheet.
If you need any assistance or wish to discuss any of these
matters, please contact my office at (202) 456-2345.
THE WHITE HOUSE
WASHINGTON
FINANCIAL DISCLOSURE REQUIREMENTS
Public Financial Disclosure
Under Federal law, you must file a public financial disclosure
report (SF-278) within 30 days of beginning employment, if you
are:
paid at a rate greater than $79,930 (in 1993) i or
a Commissioned Officer, even if paid at a lower rate.
Confidential Financial Disclosure
If you are not required to file a public report, you must file a
confidential financial disclosure report (SF-450) within 30 days
of beginning employment if you are:
in a position that has been designated as one involving
potential conflicts of interest because you have procurement
responsibilities or your job likely affects the economic
interests of persons outside the Government, or
designated as a special Government employee (SGE) (whether
compensated or not).
Ask your supervisor whether your position is or should be
designated for confidential filing.
Obtaining Forms and Filing
Financial disclosure forms are available from the White House
Counsel's Office (Room 136, X. 6229) If you are required to
file a public or confidential report, you should obtain the
appropriate form. Be sure you file with the Counsel's Office
within the statutory time limit of 30 days -- there is a $200
fine for late filing and we cannot complete our clearance without
the necessary financial disclosure reports.
THE WHITE HOUSE
WASHINGTON
MEMORANDUM
TO:
WHITE HOUSE STAFF
FROM:
WILLIAM H. KENNEDY III
ASSOCIATE COUNSEL TO THE PRESIDENT
RE:
HOW TO AVOID COMMON MISTAKES MADE ON BACKGROUND
INVESTIGATION FORMS
DATE:
SEPTEMBER 28, 1993
Please note the following before filling out the forms
contained in the Security Packet (SF 86, Tax Check Waiver,
Consent form, Etc.) Which are necessary as a condition of your
employment:
- Make sure all copies of the packet have ORIGINAL
SIGNATURES (NOT TRACED OVER A COPIED SIGNATURE) on all
pages requiring a signature.
- Make sure Tax Check Waiver forms have name, current
address, Social Security Number, date, and original
signatures.
- SF 86
* If you were born in the United States, Section 17 of
the SF 86 requires that you include CITY AND STATE
OF BIRTH for your relatives in the section the
bearing the heading "Country of Birth." If you
were born on foreign soil, please put city and
country of birth in this section.
* Include Selective Service Number if
applicable. If you do not know the number please
call 708-688-6888 for assistance.
THE WHITE HOUSE
WASHINGTON
MEMORANDUM FOR PROSPECTIVE APPOINTEES
FROM:
BERNARD W. NUSSBAUM
COUNSEL TO THE PRESIDENT
This memorandum confirms in writing your express consent for the
Federal Bureau of Investigation to investigate your background or
conduct appropriate file reviews in connection with the
consideration of your application for employment.
The FBI investigation will include the collection and use of
relevant information concerning your personal history, and it is
necessary that you authorize the disclosure of such information
to the FBI. Information may be disseminated outside the FBI when
necessary to fulfill obligations imposed by law.
By volunteering information concerning activities protected by
the First Amendment, it will be assumed that you are expressly
authorizing the maintenance of this information in the records of
any Federal agency.
If you consent to such inquiries, please sign your name below and
return this original memorandum of consent to me.
Name (please print or type)
Signature
Date
THE WHITE HOUSE
WASHINGTON
MEMORANDUM FOR PROSPECTIVE APPOINTEES
FROM:
BERNARD W. NUSSBAUM
COUNSEL TO THE PRESIDENT
This memorandum confirms in writing your express consent for the
Federal Bureau of Investigation to investigate your background or
conduct appropriate file reviews in connection with the
consideration of your application for employment.
The FBI investigation will include the collection and use of
relevant information concerning your personal history, and it is
necessary that you authorize the disclosure of such information
to the FBI. Information may be disseminated outside the FBI when
necessary to fulfill obligations imposed by law.
By volunteering information concerning activities protected by
the First Amendment, it will be assumed that you are expressly
authorizing the maintenance of this information in the records of
any Federal agency.
If you consent to such inquiries, please sign your name below and
return this original memorandum of consent to me.
Name (please print or type)
Signature
Date
To help the Internal Revenue Service find my tax records, I am
voluntarily giving the following information:
MY NAME
MY SS#:
IF MARRIED AND FILED A JOINT RETURN:
HUSBAND/WIFE NAME:
HUSBAND/WIFE SS#:
CURRENT ADDRESS
NAMES AND ADDRESSES SHOWN ON RETURNS (IF DIFFERENT FROM
ABOVE)
YEAR
NAME
ADDRESS
DATE:
(WAIVER INVALID UNLESS RECEIVED BY
INTERNAL REVENUE SERVICE WITHIN 60
DAYS OF THIS DATE)
(SIGNATURE OF TAXPAYER AUTHORIZING
THE DISCLOSURE OF RETURN INFORMATION)
TAX CHECK WAIVER
I am signing this waiver to permit the Internal Revenue
Service to release information about me which would otherwise be
confidential. This information will be used in connection with
my appointment or employment by the United States Government.
This waiver is made pursuant to 26 U.S.C. 6103 (c).
I request that the Internal Revenue Service send the
information to: President Clinton and the Office of Counsel to
the President, acting on behalf of the President.
The information I wish released is:
1. Have I failed to file any Federal income tax return which
was required to be filed for any of the last three years?
If this waiver is received by the Internal Revenue Service before
July 1, the "last three years" shall mean the latest three years
for which information is available, since the return for the
immediate last year may not have been processed.
2. Were any of these returns filed more than 45 days after the
due date for filing (determined with regard to any extension of
time for filing)
3. Have I failed to pay any tax, penalty or interest during the
last three years within 45 days of the date on which the Internal
Revenue Service gave notice of the amount due and demanded
payment?
4. Has any penalty for negligence under Section 6655 (a) of the
Internal Revenue Code been assessed against me this year or
during the last three years?
5. Am I or have I ever been under investigation by the Internal
Revenue Service for possible criminal offenses, and what were the
results of such investigation
6.
Has any civil penalty for fraud been assessed against me?
If the information which is to be released includes a "YES"
answer to any of the above six questions, I authorize the
Internal Revenue Service to release any information relative to
that question.
To help the Internal Revenue Service find my tax records, I am
voluntarily giving the following information:
MY NAME
MY SS#:
IF MARRIED AND FILED A JOINT RETURN:
HUSBAND/WIFE NAME:
HUSBAND/WIFE SS#:
CURRENT ADDRESS
NAMES AND ADDRESSES SHOWN ON RETURNS (IF DIFFERENT FROM
ABOVE)
YEAR
NAME
ADDRESS
DATE:
(WAIVER INVALID UNLESS RECEIVED BY
INTERNAL REVENUE SERVICE WITHIN 60
DAYS OF THIS DATE)
(SIGNATURE OF TAXPAYER AUTHORIZING
THE DISCLOSURE OF RETURN INFORMATION)
TAX CHECK WAIVER
I am signing this waiver to permit the Internal Revenue
Service to release information about me which would otherwise be
confidential. This information will be used in connection with
my appointment or employment by the United States Government.
This waiver is made pursuant to 26 U.S.C. 6103 (c).
I request that the Internal Revenue Service send the
information to: President Clinton and the Office of Counsel to
the President, acting on behalf of the President.
The information I wish released is:
1. Have I failed to file any Federal income tax return which
was required to be filed for any of the last three years?
If this waiver is received by the Internal Revenue Service before
July 1, the "last three years" shall mean the latest three years
for which information is available, since the return for the
immediate last year may not have been processed.
2. Were any of these returns filed more than 45 days after the
due date for filing (determined with regard to any extension of
time for filing)?
3. Have I failed to pay any tax, penalty or interest during the
last three years within 45 days of the date on which the Internal
Revenue Service gave notice of the amount due and demanded
payment?
4. Has any penalty for negligence under Section 6655 (a) of the
Internal Revenue Code been assessed against me this year or
during the last three years?
5. Am I or have I ever been under investigation by the Internal
Revenue Service for possible criminal offenses, and what were the
results of such investigation(s
6.
Has any civil penalty for fraud been assessed against me?
If the information which is to be released includes a "YES"
answer to any of the above six questions, I authorize the
Internal Revenue Service to release any information relative to
that question.
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Standard Form 86
Form approved:
Revised December 1990
O.M.B. No. 3206-0007
NSN 7540-00-634-4036
U.S.Office of Personnel Management
86-110
FPM Chapter 732
Questionnaire for Sensitive Positions
(For
National
Security)
Read this information carefully. Follow the instructions fully or we cannot process your form.
Why do we need the information you will give us and how
If your investigation requires a Personal Subject Interview, you
will we use it?
will be contacted in advance by telephone or mail to arrange a
time and location for the interview. It is important that the
The U.S. Government has conducted background investigations
interview be conducted as soon as possible after you are con-
for over 50 years. It does this to establish that applicants for or
tacted. Postponements will delay the processing of your inves-
incumbents in sensitive positions, either employed by the Gov-
tigation. Declining an interview may result in your investigation
ernment or working for the Government under contract, are
being delayed or canceled.
eligible for a required security clearance or for performing
sensitive duties. We use the information from this form
You will be asked to bring identification with your picture on it,
primarily as the basis for an investigation that will be used to
such as a valid State driver's license, to the interview. There are
determine your eligibility for a national security position.
other documents you may be asked to bring to verify your
identity as well. These include: documentation of any legal name
The information you give us is for Official Use Only; we will
change; Social Security card; and/or birth certificate.
protect it from unauthorized disclosure. Authorized disclosures
include the Privacy Act Routine Uses shown on this form. The
Documents that verify any significant claims or activities may
information you provide in response to question 25a on use of
also be requested, for example: alien registration; naturalization
illegal drugs will not be provided for use in any criminal pro-
certificate; originals or certified copies. of college transcripts or
ceedings against you.
degrees; high school diploma; professional license(s) or
certificate(s); military discharge certificate(s) (DD Form 214);
Giving us the information we ask for is voluntary. However, we
marriage certificate(s); passport; and/or business license(s). You
may not be able to complete your investigation, or complete it in
also may be asked to bring documents that pertain to
a timely manner, if you don't give us each item of information we
information provided in your answers to questions on the form
request. This may affect your placement or clearance prospects.
or other matters requiring specific attention. These matters
include: termination or discharge from employment; delinquent
What authority do we have to ask you for the information
loans or taxes, bankruptcy, judgments, liens, or other financial
requested on this form?
obligations; and arrests, convictions, probation and/or parole.
The U.S. Government is authorized to ask for this information
Who makes a final determination?
under Executive Order 10450; section 2165 of title 42, U.S. Code;
parts 5, 732, and 736 of Title 5, Code of Federal Regulations, and
Final determination on your eligibility for a national security
other statutes authorizing background investigations. We ask for
position and your being granted a clearance is the responsibility
your Social Security number to keep our records accurate,
of the OPM or the Federal agency that requested your
because other people may have the same name and birth date.
investigation. You may be provided the opportunity to personally
Executive Order 9397 also asks Federal agencies to use this
explain, refute, or clarify any information before a final decision
number to help identify individuals in agency records.
is made.
What is the investigative process?
How is this form organized?
Background investigations for national security are conducted to
This form has two parts. Part 1 asks for background
develop information to show whether or not a person is reliable,
information, including where you have lived, gone to school, and
trustworthy, of good conduct and character, and loyal to the
worked. Part 2 asks about your activities and such matters as
United States. The information you provide on this form,
firings from a job, criminal history record, use of illegal drugs and
including any specific agency instructions of Question 14c., and
alcohol consumption. In answering Part 2, you should keep in
any other special instructions, is confirmed by investigation.
mind that your answers to questions are considered together
Your current employer must be contacted, even if you indicated
with the information obtained in the investigation to reach an
on your SF 171, or other form, that you do not want the present
appropriate adjudication for a sensitive position.
employer contacted. In addition to the questions on this form,
inquiry also is made about a person's adherence to security
What are the penalties for inaccurate or false statements?
requirements, mental or health disorders, dishonest conduct,
sexual misconduct, vulnerability to blackmail or coercion,
The U.S. Criminal Code provides that knowingly falsifying or
falsification, misrepresentation and any other behavior, activities,
concealing a material fact is a felony which may result in fines
or associations that tend to show the person is not reliable,
of up to $10,000, or 5 years imprisonment, or both. In addition,
trustworthy, or loyal.
Federal agencies generally fire, do not grant clearance, or
disqualify individuals who have materially and deliberately falsi-
An interview with you is a normal part of the investigative
fied these forms, and this remains a part of our permanent
process. This Personal Subject Interview is generally the first
record for future placements. Because the position for which you
step in the investigation, and is conducted under oath, affir-
are being considered is a sensitive one, your trustworthiness is
mation, or unsworn declaration. It provides you the opportunity
a very important consideration in deciding your eligibility for
to update, clarify, and explain more completely information on
security clearance. Your prospects of placement or clearance are
your form, which often helps to complete your investigation fast-
better if you answer all questions truthfully and completely. In
er.
the course of an interview with a Federal official you will have
Standard Form 86A
,ONTINUATION SHEET FOR QL
TIONNAIRES
Form approved:
Revised December 1990
SF 86, SF 85P, AND SF 85
O.M.B. No. 3206-0007
U.S.Office of Personnel Management
For use with the SF 86, Questionnaire for Sensitive Positions (for National Security);
NSN 7540-01-268-4828
FPM Chapter 736
SF 85P, Questionnaire for Public Trust Positions;
86-202
and SF 85, Questionnaire for Non-Sensitive Positions
INSTRUCTIONS: Use this form to continue your answers to "Where You Have Lived" and/or "Your Employment Activities." Follow the instructions on the form for the particular
questions you are answering and give information in the same sequence. Use as many continuation sheets as you need to furnish all the requested information.
Your Name
Your Social Security Number
-
-
WHERE YOU HAVE LIVED (Continued)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knows You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
( )
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
YOUR EMPLOYMENT ACTIVITIES (Continued)
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
( )
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
YOUR EMPLOYMENT ACTIVITIES (Continued)
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
( )
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
( )
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
( )
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
( )
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Enter your Social Security Number
-
-
Standard Form 86A (Back)
December 1990
Standard Form 86A
CONTINUATION SHEET FOR QUI STIONNAIRES
Form approved:
Revised December 1990
SF 86, SF 85P, AND SF 85
O.M.B. No. 3206-0007
U.S.Office of Personnel Management
For use with the SF 86, Questionnaire for Sensitive Positions (for National Security);
NSN 7540-01-268-4828
FPM Chapter 736
SF 85P, Questionnaire for Public Trust Positions;
86-202
and SF 85, Questionnaire for Non-Sensitive Positions
INSTRUCTIONS: Use this form to continue your answers to "Where You Have Lived" and/or "Your Employment Activities." Follow the instructions on the form for the particular
questions you are answering and give information in the same sequence. Use as many continuation sheets as you need to furnish all the requested information.
Your Name
Your Social Security Number
-
-
WHERE YOU HAVE LIVED (Continued)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knows You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code:
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt.#
City (Country)
State
ZIP Code
Telephone Number
( )
YOUR EMPLOYMENT ACTIVITIES (Continued)
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
( )
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
( )
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
( )
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
( )
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
YOUR EMPLOYMENT ACTIVITIES (Continued)
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Month/Year Month/Year
Code
Employer's Name/Military Service/Unemployment or Self-Employment Verifier
Your Position Title
To
Employer's/Verifier's Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer's Address)
City (Country)
State
ZIP Code
Telephone Number
( )
Supervisor's Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
PREVIOUS PERIODS OF THE SAME ACTIVITY AND LOCATION - IF CONTINUATION SHEET IS USED, SHOW BLOCK #
Month/Year Month/Year
Your Position Title & Supervisor's Name
Month/Year Month/Year
Your Position Title & Supervisor's Name
To
To
To
To
Enter your Social Security Number
-
-
Standard Form 86A (Back)
December 1990
THE WHITE HOUSE
WASHINGTON
PERSONAL DATA STATEMENT QUESTIONNAIRE
FROM:
BERNARD W. NUSSBAUM
COUNSEL TO THE PRESIDENT
As part of the clearance procedures for your prospective
position, please answer all of the following questions (please do
not respond "not applicable" or "N/A" if your response is "no" or
"none"). In responding to the questions, please supply any
information regarding your spouse or relatives that you deem to
be relevant. Your responses to this questionnaire, which is not
subject to public disclosure, are confidential.
You can type your responses in memorandum form on a separate
sheet of paper with each answer corresponding to the number of
the question. You do not need to retype the questions, but
please sign and date the response.
Because your appointment cannot be finalized until all necessary
reviews have been completed, please supply this information
within 24 hours to Edgar Bueno of my staff. (old Executive
Office Building, Room 136, Washington, D.C. 20500; fax number:
(202) 456-2146).
If you have any questions or need assistance in responding to
this questionnaire, please do not hesitate to contact this office
at 202-456-6229. Thank you for your cooperation.
Personal and Family Background
1. Please list your full name; home address and telephone
number; office address and telephone number; date and place of
birth; citizenship; and social security number.
2. Please identify your current marital status; spouse's name,
citizenship, occupation, and current employer; and the names and
ages of your children.
3. Do you have any medical conditions that could interfere with
your ability to fulfill your duties? Please explain.
Professional and Educational Background
4. Please list each high school, college, and graduate school
you attended; the dates of your attendance; and degrees awarded.
5. Please furnish a copy of your resume and a brief
biographical statement.
6. Please chronologically list activities, other than those
listed on your resume, from which you have derived earned income
(e.g., self-employment, consulting activities, writing, speaking,
royalties, and honoraria) since age 21.
7. Please list each book, article, or publication you have
authored, individually or with others.
8. Identify each instance in which you have testified before
Congress in a non-governmental capacity and specify the subject
matter of each testimony.
9. Please list all corporations, partnerships, trusts, or other
business entities with which you have ever been affiliated as an
officer, director, trustee, partner, or holder of a significant
equity or financial interest (i.e., any ownership interest of
more than 5%), or whose decisions you had the ability to
influence.
2
10. Please provide the names of all corporations, firms,
partnerships, trusts, or other business enterprises, and all non-
profit organizations and other institutions with which you are
now, or during the past five years have been, affiliated as an
advisor, attorney or consultant. It is only necessary to provide
the names of major clients and any client matter in which you and
your firm are involved that might present a potential conflict of
interest with your proposed assignment. Please identify the
clients by name unless it would breach a confidential
relationship or duty respecting a privileged matter. In
addition, please provide the names of any other organizations
with which you were associated which might present a potential
conflict or the appearance of conflict of interest with your
prospective appointment.
11. Please describe any contractual or informal arrangement you
may have made with any person or any business enterprise in
regard to future employment or termination payments or financial
benefits that will be provided you if you enter government
employment.
12. If you are a member of any licensed profession or occupation
(such as lawyer, doctor, accountant, insurance or real estate
broker, etc.), please specify: the present status of each
license; and whether any such license has ever been withdrawn,
suspended, or revoked, and the reason therefor.
13. Does your spouse or any family member or business in which
you, your spouse or any family members have a significant
interest have any relationship with the federal government
through contracts, consulting services, grants, loans or
guarantees? If yes, please provide details.
3
14. If you have performed any work for and/or received any
payments from any foreign government, business, or individual in
the past 10 years, please describe the circumstances, and
identify the source and amount.
15. Please list any registration as an agent for a foreign
principal, or any exemption from such registration.
16. Have you ever registered as a lobbyist or other legislative
agent to influence federal or state legislation or administrative
acts? If yes, please supply details.
Tax and Financial Information
17. As of the date of this questionnaire, please list all assets
and liabilities with a fair market value in excess of $5,000 for
you and your spouse and provide a good faith estimate of value.
As to liabilities, please list the name and address of the
creditor, the amount owed to the nearest thousand dollar, a brief
description of the nature of the obligation, the interest rate
(if any), and the date on which due.
18. Please describe all real estate held in your name or in your
spouse's name during the last six years, including any real
estate held in combination with others or on your or your
spouse's behalf in trust, by a nominee, or through any other
title-holding entity.
19. Have you and your spouse filed all federal, state and local
income tax returns?
4
20. Have you or your spouse ever filed a late income tax return
without a valid extension? If so, describe the circumstances and
the resolution of the matter.
21. Have you or your spouse ever paid any tax penalties? If so,
describe the circumstances and the resolution of the matter.
22. Has a tax lien or other collection procedure ever been
instituted against your or your spouse by federal, state or local
authorities? If so, describe the circumstances and the
resolution of the matter.
Public and Organizational Activities
23. Please list current and past political party affiliations.
24. Please list each membership you have had with any civic,
social, charitable, educational, professional, fraternal,
benevolent or religious organization, private club, or other
membership organization (including any tax-exempt organization)
during the past 10 years.
25. Have you or your spouse at any time belonged to any
membership organization, including but not limited to those
described in the preceding paragraph, that as a matter of policy
or practice denied or restricted affiliation (as a matter of
either policy or practice) based on race, sex, ethnic background,
religious or sexual preference?
5
Legal and Administrative Proceedings and Filings
26. Please list any lawsuits you have brought as a plaintiff or
which were brought against you as a defendant or third party.
Include in this response any contested divorce proceedings or
other domestic relations matters.
27. Please list and describe any administrative agency
proceeding in which you have been involved as a party.
28. Please list any bankruptcy proceeding in which you or your
spouse have been involved as a debtor.
29. Have you or your spouse ever been investigated by any
federal, state, military or local law enforcement agency, or
arrested for, charged with, or convicted of violating any
federal, state or local law, regulation or ordinance (excluding
traffic offenses for which the fine was less than $100) ? If so,
please identify each such instance and supply details, including:
date; place; law enforcement agency; and court.
30. Please list any complaint ever made against you or by any
administrative agency, professional association or organization,
or federal, state or local ethics agency, committee, or official.
6
Miscellaneous
31. Have you ever had any association with any person, group or
business venture that could be used, even unfairly, to impugn or
attack your character and qualifications for a government
position?
32. Do you know anyone or any organization that might take any
steps, overtly or covertly, fairly or unfairly, to criticize your
appointment, including any news organization? If so, please
identify and explain the basis for the potential criticism.
33. Please provide any other information, including information
about other members of your family, that could suggest a conflict
of interest or be a possible source of embarrassment to you, your
family or the President.
7
THE WHITE HOUSE
WASHINGTON
MEMORANDUM
TO: WHITE HOUSE OFFICE STAFF
FR: BERNARD NUSSBAUM
COUNSEL TO THE PRESIDENT
Before a final decision on your employment can be made, certain
background investigations and conflict-of-interest reviews must
be completed. Accordingly, I am providing you with the enclosed
package of security clearance forms and questionnaires for your
completion. The FBI cannot begin its full-field investigation
until we receive your typed, completed and signed forms.
Completed packages should consist of:
Item
Number We Need
1. Questionnaire for
One original and THREE
Sensitive Positions
copies, all with original
(SF 86) plus any
signatures. NOTE: the
attachments
SF 86 requires two signatures
2. Consent Memorandum from
One Original and one copy,
Bernard Nussbaum
both with original signatures
3. Tax Check Waiver
TWO signed originals
THESE FORMS MUST BE TYPED
COMPLETED, EXECUTED, AND RETURNED AS SOON AS
POSSIBLE (PREFERABLLY WITHIN 3 DAYS) TO MR. CRAIG
LIVINGSTONE, DIRECTOR, WHITE HOUSE SECURITY
PERSONNEL SECURITY OFFICE, (OEOB, ROOM 84)
4.
Personal Data Statement
Original. This Questionnaire
only is to be returned to
Mr. Edgar Bueno, Office of
Counsel to the President,
Room 136, OEOB.
For information about financial disclosure, please see
enclosed sheet.
If you need any assistance or wish to discuss any of these
matters, please contact my office at (202) 456-2345.
THE WHITE HOUSE
WASHINGTON
FINANCIAL DISCLOSURE REQUIREMENTS
Public Financial Disclosure
Under Federal law, you must file a public financial disclosure
report (SF-278) within 30 days of beginning employment, if you
are:
paid at a rate greater than $79,930 (in 1993) ; or
a Commissioned Officer, even if paid at a lower rate.
Confidential Financial Disclosure
If you are not required to file a public report, you must file a
confidential financial disclosure report (SF-450) within 30 days
of beginning employment if you are:
in a position that has been designated as one involving
potential conflicts of interest because you have procurement
responsibilities or your job likely affects the economic
interests of persons outside the Government, or
designated as a special Government employee (SGE) (whether
compensated or not)
Ask your supervisor whether your position is or should be
designated for confidential filing.
Obtaining Forms and Filing
Financial disclosure forms are available from the White House
Counsel's Office (Room 136, X. 6229) If you are required to
file a public or confidential report, you should obtain the
appropriate form. Be sure you file with the Counsel's Office
within the statutory time limit of 30 days -- there is a $200
fine for late filing and we cannot complete our clearance without
the necessary financial disclosure reports.
THE WHITE HOUSE
WASHINGTON
MEMORANDUM
TO:
WHITE HOUSE STAFF
FROM:
WILLIAM H. KENNEDY III
ASSOCIATE COUNSEL TO THE PRESIDENT
RE:
HOW TO AVOID COMMON MISTAKES MADE ON BACKGROUND
INVESTIGATION FORMS
DATE:
SEPTEMBER 28, 1993
Please note the following before filling out the forms
contained in the Security Packet (SF 86, Tax Check Waiver,
Consent form, Etc.) Which are necessary as a condition of your
employment:
- Make sure all copies of the packet have ORIGINAL
SIGNATURES (NOT TRACED OVER A COPIED SIGNATURE) on all
pages requiring a signature.
- Make sure Tax Check Waiver forms have name, current
address, Social Security Number, date, and original
signatures.
- SF 86
* If you were born in the United States, Section 17 of
the SF 86 requires that you include CITY AND STATE
OF BIRTH for your relatives in the section the
bearing the heading "Country of Birth." If you
were born on foreign soil, please put city and
country of birth in this section.
* Include Selective Service Number if
applicable. If you do not know the number please
call 708-688-6888 for assistance.
THE WHITE HOUSE
WASHINGTON
MEMORANDUM FOR PROSPECTIVE APPOINTEES
FROM:
BERNARD W. NUSSBAUM
COUNSEL TO THE PRESIDENT
This memorandum confirms in writing your express consent for the
Federal Bureau of Investigation to investigate your background or
conduct appropriate file reviews in connection with the
consideration of your application for employment.
The FBI investigation will include the collection and use of
relevant information concerning your personal history, and it is
necessary that you authorize the disclosure of such information
to the FBI. Information may be disseminated outside the FBI when
necessary to fulfill obligations imposed by law.
By volunteering information concerning activities protected by
the First Amendment, it will be assumed that you are expressly
authorizing the maintenance of this information in the records of
any Federal agency.
If you consent to such inquiries, please sign your name below and
return this original memorandum of consent to me.
Name (please print or type)
Signature
Date
THE WHITE HOUSE
WASHINGTON
MEMORANDUM FOR PROSPECTIVE APPOINTEES
FROM:
BERNARD W. NUSSBAUM
COUNSEL TO THE PRESIDENT
This memorandum confirms in writing your express consent for the
Federal Bureau of Investigation to investigate your background or
conduct appropriate file reviews in connection with the
consideration of your application for employment.
The FBI investigation will include the collection and use of
relevant information concerning your personal history, and it is
necessary that you authorize the disclosure of such information
to the FBI. Information may be disseminated outside the FBI when
necessary to fulfill obligations imposed by law.
By volunteering information concerning activities protected by
the First Amendment, it will be assumed that you are expressly
authorizing the maintenance of this information in the records of
any Federal agency.
If you consent to such inquiries, please sign your name below and
return this original memorandum of consent to me.
Name (please print or type)
Signature
Date
To help the Internal Revenue Service find my tax records, I am
voluntarily giving the following information:
MY NAME
MY SS#:
IF MARRIED AND FILED A JOINT RETURN:
HUSBAND/WIFE NAME:
HUSBAND/WIFE SS#:
CURRENT ADDRESS
NAMES AND ADDRESSES SHOWN ON RETURNS (IF DIFFERENT FROM
ABOVE)
YEAR
NAME
ADDRESS
DATE:
(WAIVER INVALID UNLESS RECEIVED BY
INTERNAL REVENUE SERVICE WITHIN 60
DAYS OF THIS DATE)
(SIGNATURE OF TAXPAYER AUTHORIZING
THE DISCLOSURE OF RETURN INFORMATION)
TAX CHECK WAIVER
I am signing this waiver to permit the Internal Revenue
Service to release information about me which would otherwise be
confidential. This information will be used in connection with
my appointment or employment by the United States Government.
This waiver is made pursuant to 26 U.S.C. 6103 (c).
I request that the Internal Revenue Service send the
information to: President Clinton and the Office of Counsel to
the President, acting on behalf of the President.
The information I wish released is:
1. Have I failed to file any Federal income tax return which
was required to be filed for any of the last three years?
If this waiver is received by the Internal Revenue Service before
July 1, the "last three years" shall mean the latest three years
for which information is available, since the return for the
immediate last year may not have been processed.
2. Were any of these returns files more than 45 days after the
due date for filing (determined with regard to any extension of
time for filing) ?
3. Have I failed to pay any tax, penalty or interest during the
last three years within 45 days of the date on which the Internal
Revenue Service gave notice of the amount due and demanded
payment?
4. Has any penalty for negligence under Section 6655 (a) of the
Internal Revenue Code been assessed against me this year or
during the last three years?
5. Am I or have I ever been under investigation by the Internal
Revenue Service for possible criminal offenses, and what were the
results of such investigation(s)
6.
Has any civil penalty for fraud been assessed against me?
If the information which is to be released includes a "YES"
answer to any of the above six questions, I authorize the
Internal Revenue Service to release any information relative to
that question.
To help the Internal Revenue Service find my tax records, I am
voluntarily giving the following information:
MY NAME
MY SS#:
IF MARRIED AND FILED A JOINT RETURN:
HUSBAND/WIFE NAME:
HUSBAND/WIFE SS#:
CURRENT ADDRESS
NAMES AND ADDRESSES SHOWN ON RETURNS (IF DIFFERENT FROM
ABOVE)
YEAR
NAME
ADDRESS
DATE:
(WAIVER INVALID UNLESS RECEIVED BY
INTERNAL REVENUE SERVICE WITHIN 60
DAYS OF THIS DATE)
(SIGNATURE OF TAXPAYER AUTHORIZING
THE DISCLOSURE OF RETURN INFORMATION)
TAX CHECK WAIVER
I am signing this waiver to permit the Internal Revenue
Service to release information about me which would otherwise be
confidential. This information will be used in connection with
my appointment or employment by the United States Government.
This waiver is made pursuant to 26 U.S.C. 6103 (c).
I request that the Internal Revenue Service send the
information to: President Clinton and the Office of Counsel to
the President, acting on behalf of the President.
The information I wish released is:
1. Have I failed to file any Federal income tax return which
was required to be filed for any of the last three years?
If this waiver is received by the Internal Revenue Service before
July 1, the "last three years" shall mean the latest three years
for which information is available, since the return for the
immediate last year may not have been processed.
2. Were any of these returns filed more than 45 days after the
due date for filing (determined with regard to any extension of
time for filing)?
3. Have I failed to pay any tax, penalty or interest during the
last three years within 45 days of the date on which the Internal
Revenue Service gave notice of the amount due and demanded
payment?
4. Has any penalty for negligence under Section 6655 (a) of the
Internal Revenue Code been assessed against me this year or
during the last three years?
5. Am I or have I ever been under investigation by the Internal
Revenue Service for possible criminal offenses, and what were the
results of such investigation(s
6.
Has any civil penalty for fraud been assessed against me?
If the information which is to be released includes a "YES"
answer to any of the above six questions, I authorize the
Internal Revenue Service to release any information relative to
that question.
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Standard Form 86
Form approved:
Revised December 1990
O.M.B. No. 3206-0007
NSN 7540-00-634-4036
U.S.Office of Personnel Management
86-110
FPM Chapter 732
Questionnaire for Sensitive Positions
(For National Security)
Read this information carefully. Follow the instructions fully or we cannot process your form.
Why do we need the information you will give us and how
If your investigation requires a Personal Subject Interview, you
will we use it?
will be contacted in advance by telephone or mail to arrange a
time and location for the interview. It is important that the
The U.S. Government has conducted background investigations
interview be conducted as soon as possible after you are con-
for over 50 years. It does this to establish that applicants for or
tacted. Postponements will delay the processing of your inves-
incumbents in sensitive positions, either employed by the Gov-
tigation. Declining an interview may result in your investigation
ernment or working for the Government under contract, are
being delayed or canceled.
eligible for a required security clearance or for performing
sensitive duties. We use the information from this form
You will be asked to bring identification with your picture on it,
primarily as the basis for an investigation that will be used to
such as a valid State driver's license, to the interview. There are
determine your eligibility for a national security position.
other documents you may be asked to bring to verify your
identity as well. These include: documentation of any legal name
The information you give us is for Official Use Only; we will
change; Social Security card; and/or birth certificate.
protect it from unauthorized disclosure. Authorized disclosures
include the Privacy Act Routine Uses shown on this form. The
Documents that verify any significant claims or activities may
information you provide in response to question 25a on use of
also be requested, for example: alien registration; naturalization
illegal drugs will not be provided for use in any criminal pro-
certificate; originals or certified copies. of college transcripts or
ceedings against you.
degrees; high school diploma; professional license(s) or
certificate(s); military discharge certificate(s) (DD Form 214);
Giving us the information we ask for is voluntary. However, we
marriage certificate(s); passport; and/or business license(s). You
may not be able to complete your investigation, or complete it in
also may be asked to bring documents that pertain to
a timely manner, if you don't give us each item of information we
information provided in your answers to questions on the form
request. This may affect your placement or clearance prospects.
or other matters requiring specific attention. These matters
include: termination or discharge from employment; delinquent
What authority do we have to ask you for the information
loans or taxes, bankruptcy, judgments, liens, or other financial
requested on this form?
obligations; and arrests, convictions, probation and/or parole.
The U.S. Government is authorized to ask for this information
Who makes a final determination?
under Executive Order 10450; section 2165 of title 42, U.S. Code;
parts 5, 732, and 736 of Title 5, Code of Federal Regulations, and
Final determination on your eligibility for a national security
other statutes authorizing background investigations. We ask for
position and your being granted a clearance is the responsibility
your Social Security number to keep our records accurate,
of the OPM or the Federal agency that requested your
because other people may have the same name and birth date.
investigation. You may be provided the opportunity to personally
Executive Order 9397 also asks Federal agencies to use this
explain, refute, or clarify any information before a final decision
number to help identify individuals in agency records.
is made.
What is the investigative process?
How is this form organized?
Background investigations for national security are conducted to
This form has two parts. Part 1 asks for background
develop information to show whether or not a person is reliable,
information, including where you have lived, gone to school, and
trustworthy, of good conduct and character, and loyal to the
worked. Part 2 asks about your activities and such matters as
United States. The information you provide on this form,
firings from ajob, criminal history record, use of illegal drugs and
including any specific agency instructions of Question 14c., and
alcohol consumption. In answering Part 2, you should keep in
any other special instructions, is confirmed by investigation.
mind that your answers to questions are considered together
Your current employer must be contacted, even if you indicated
with the information obtained in the investigation to reach an
on your SF 171, or other form, that you do not want the present
appropriate adjudication for a sensitive position.
employer contacted. In addition to the questions on this form,
inquiry also is made about a person's adherence to security
What are the penalties for inaccurate or false statements?
requirements, mental or health disorders, dishonest conduct,
sexual misconduct, vulnerability to blackmail or coercion,
The U.S. Criminal Code provides that knowingly falsifying or
falsification, misrepresentation and any other behavior, activities,
concealing a material fact is a felony which may result in fines
or associations that tend to show the person is not reliable,
of up to $10,000, or 5 years imprisonment, or both. In addition,
trustworthy, or loyal.
Federal agencies generally fire, do not grant clearance, or
disqualify individuals who have materially and deliberately falsi-
An interview with you is a normal part of the investigative
fied these forms, and this remains a part of our permanent
process. This Personal Subject Interview is generally the first
record for future placements. Because the position for which you
step in the investigation, and is conducted under oath, affir-
are being considered is a sensitive one, your trustworthiness is
mation, or unsworn declaration. It provides you the opportunity
a very important consideration in deciding your eligibility for
to update, clarify, and explain more completely information on
security clearance. Your prospects of placement or clearance are
your form, which often helps to complete your investigation fast-
better if you answer all questions truthfully and completely. In
er.
the course of an interview with a Federal official you will have
THE WHITE HOUSE
WASHINGTON
PERSONAL DATA STATEMENT QUESTIONNAIRE
FROM:
BERNARD W. NUSSBAUM
COUNSEL TO THE PRESIDENT
As part of the clearance procedures for your prospective
position, please answer all of the following questions (please do
not respond "not applicable" or "N/A" if your response is "no" or
"none"). In responding to the questions, please supply any
information regarding your spouse or relatives that you deem to
be relevant. Your responses to this questionnaire, which is not
subject to public disclosure, are confidential.
You can type your responses in memorandum form on a separate
sheet of paper with each answer corresponding to the number of
the question. You do not need to retype the questions, but
please sign and date the response.
Because your appointment cannot be finalized until all necessary
reviews have been completed, please supply this information
within 24 hours to Edgar Bueno of my staff. (Old Executive
Office Building, Room 136, Washington, D.C. 20500; fax number:
(202) 456-2146).
If you have any questions or need assistance in responding to
this questionnaire, please do not hesitate to contact this office
at 202-456-6229. Thank you for your cooperation.
Personal and Family Background
1. Please list your full name; home address and telephone
number; office address and telephone number; date and place of
birth; citizenship; and social security number.
2. Please identify your current marital status; spouse's name,
citizenship, occupation, and current employer; and the names and
ages of your children.
3. Do you have any medical conditions that could interfere with
your ability to fulfill your duties? Please explain.
Professional and Educational Background
4. Please list each high school, college, and graduate school
you attended; the dates of your attendance; and degrees awarded.
5. Please furnish a copy of your resume and a brief
biographical statement.
6. Please chronologically list activities, other than those
listed on your resume, from which you have derived earned income
(e.g., self-employment, consulting activities, writing, speaking,
royalties, and honoraria) since age 21.
7. Please list each book, article, or publication you have
authored, individually or with others.
8. Identify each instance in which you have testified before
Congress in a non-governmental capacity and specify the subject
matter of each testimony.
9. Please list all corporations, partnerships, trusts, or other
business entities with which you have ever been affiliated as an
officer, director, trustee, partner, or holder of a significant
equity or financial interest (i.e., any ownership interest of
more than 5%), or whose decisions you had the ability to
influence.
2
10. Please provide the names of all corporations, firms,
partnerships, trusts, or other business enterprises, and all non-
profit organizations and other institutions with which you are
now, or during the past five years have been, affiliated as an
advisor, attorney or consultant. It is only necessary to provide
the names of major clients and any client matter in which you and
your firm are involved that might present a potential conflict of
interest with your proposed assignment. Please identify the
clients by name unless it would breach a confidential
relationship or duty respecting a privileged matter. In
addition, please provide the names of any other organizations
with which you were associated which might present a potential
conflict or the appearance of conflict of interest with your
prospective appointment.
11. Please describe any contractual or informal arrangement you
may have made with any person or any business enterprise in
regard to future employment or termination payments or financial
benefits that will be provided you if you enter government
employment.
12. If you are a member of any licensed profession or occupation
(such as lawyer, doctor, accountant, insurance or real estate
broker, etc.), please specify: the present status of each
license; and whether any such license has ever been withdrawn,
suspended, or revoked, and the reason therefor.
13. Does your spouse or any family member or business in which
you, your spouse or any family members have a significant
interest have any relationship with the federal government
through contracts, consulting services, grants, loans or
guarantees? If yes, please provide details.
3
14. If you have performed any work for and/or received any
payments from any foreign government, business, or individual in
the past 10 years, please describe the circumstances, and
identify the source and amount.
15. Please list any registration as an agent for a foreign
principal, or any exemption from such registration.
16. Have you ever registered as a lobbyist or other legislative
agent to influence federal or state legislation or administrative
acts? If yes, please supply details.
Tax and Financial Information
17. As of the date of this questionnaire, please list all assets
and liabilities with a fair market value in excess of $5,000 for
you and your spouse and provide a good faith estimate of value.
As to liabilities, please list the name and address of the
creditor, the amount owed to the nearest thousand dollar, a brief
description of the nature of the obligation, the interest rate
(if any), and the date on which due.
18. Please describe all real estate held in your name or in your
spouse's name during the last six years, including any real
estate held in combination with others or on your or your
spouse's behalf in trust, by a nominee, or through any other
title-holding entity.
19. Have you and your spouse filed all federal, state and local
income tax returns?
4
20. Have you or your spouse ever filed a late income tax return
without a valid extension? If so, describe the circumstances and
the resolution of the matter.
21. Have you or your spouse ever paid any tax penalties? If so,
describe the circumstances and the resolution of the matter.
22. Has a tax lien or other collection procedure ever been
instituted against your or your spouse by federal, state or local
authorities? If so, describe the circumstances and the
resolution of the matter.
Public and Organizational Activities
23. Please list current and past political party affiliations.
24. Please list each membership you have had with any civic,
social, charitable, educational, professional, fraternal,
benevolent or religious organization, private club, or other
membership organization (including any tax-exempt organization)
during the past 10 years.
25. Have you or your spouse at any time belonged to any
membership organization, including but not limited to those
described in the preceding paragraph, that as a matter of policy
or practice denied or restricted affiliation (as a matter of
either policy or practice) based on race, sex, ethnic background,
religious or sexual preference?
5
Legal and Administrative Proceedings and Filings
26. Please list any lawsuits you have brought as a plaintiff or
which were brought against you as a defendant or third party.
Include in this response any contested divorce proceedings or
other domestic relations matters.
27. Please list and describe any administrative agency
proceeding in which you have been involved as a party.
28. Please list any bankruptcy proceeding in which you or your
spouse have been involved as a debtor.
29. Have you or your spouse ever been investigated by any
federal, state, military or local law enforcement agency, or
arrested for, charged with, or convicted of violating any
federal, state or local law, regulation or ordinance (excluding
traffic offenses for which the fine was less than $100) ? If so,
please identify each such instance and supply details, including:
date; place; law enforcement agency; and court.
30. Please list any complaint ever made against you or by any
administrative agency, professional association or organization,
or federal, state or local ethics agency, committee, or official.
6
Miscellaneous
31. Have you ever had any association with any person, group or
business venture that could be used, even unfairly, to impugn or
attack your character and qualifications for a government
position?
32. Do you know anyone or any organization that might take any
steps, overtly or covertly, fairly or unfairly, to criticize your
appointment, including any news organization? If so, please
identify and explain the basis for the potential criticism.
33. Please provide any other information, including information
about other members of your family, that could suggest a conflict
of interest or be a possible source of embarrassment to you, your
family or the President.
7