Fillable Form Gsa 850 - Temporary Contractor Information Worksheet

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

PURPOSE OF THIS FORM

The U.S. Government conducts criminal checks and Citizenship & Immigration Status

Solicitation of information contained herein may be used as a basis for

Checks to establish that applicants or incumbents working for the Government under

physical access determinations. GSA describes how your information will

contract may have unescorted access to GSA-controlled facilities. GSA will use this

be maintained in the Privacy Act system of record notice published in the

form and the FBI form FD-258 Fingerprint Card to conduct a FBI National Criminal

Federal Register at 73 FR 35690 on June 24, 2008. Your social security

Information Check (NCIC) for each temporary contractor (working on contract 6

number is being requested pursuant to Executive Order 9397. Disclosure

months or less and require physical access only) on GSA contracts for American

of the information by you is voluntary. Failure to provide information

Recovery and Reinvestment Act of 2009 efforts only. This form: authorizes the request

for a NCIC and Citizenship & Immigration Status Check; describes the authority to

requested on this form may result in the government’s inability, to grant

collect and share the required information; and identifies the temporary contractor to

unescorted physical access to GSA-controlled facilities and may affect

GSA contract, building, and vendor information. A favorable entry on duty

your prospects for employment or continued employment under a

determination from the NCIC and Central Index Check System (CIS) is required to

government contract, or at a Federal facility, or with a government license.

receive unescorted physical access to GSA-controlled facilities.

AUTHORITY TO REQUEST THIS INFORMATION

PRIVACY ACT ROUTINE USES

The Office of Management and Budget (OMB) Guidance M-05-24 for Homeland

To GSA Personnel when needed for official business, including the Security

Security Presidential Directive (HSPD) 12 requires Federal departments and

Office, HSPD -12 Points of Contacts, and designated analysts and managers

agencies to ensure that temporary contractors have limited/controlled access to

for official business; and PIV card requesting officials to track, verify, and

facilities and information systems. GSA Directive CIO P 2181.1, Homeland

update identity information of GSA personnel; and Regional Credential

Security Presidential Directive-12 Personal Identity Verification and

Officers (RCOs) to issue and track PIV ID cards;

To verify eligibility of an employee or contractor before granting access to

Credentialing, provides that GSA temporary contractors must undergo a

specific resources;

minimum of a FBI National Criminal Information Check (NCIC) and Citizenship &

To disclose information to agency staff and administrative offices who may

Immigration Status Check to receive unescorted physical access. DHS/ICE/FPS

restructure the data for management purposes;

will transmit the access determination electronically to designated GSA officials

An authoritative source of identities for Active Directory and Lotus Notes and

and the temporary contractor's company.

other GSA systems;

In any legal proceeding, where pertinent, to which GSA is a party before a

THE BACKGROUND CHECK PROCESS

court or administrative body;

GSA submits this completed form and your 10-digit fingerprints on the FBI Form

To authorized officials engaged in investigating or settling a grievance,

FD-258 Fingerprint Card to the U.S. Department of Homeland Security

complaint, or appeal filed by an individual who is the subject of the record.

Immigration and Customs Enforcement, Federal Protective Service (DHS/ICE/

To a Federal, state, local, foreign, or tribal agency in connection with the

FPS) to process the background investigation request per the terms of agreement

hiring or retention of an employee; the issuance of a security clearance; the

in two separate Memorandums of Agreement (MOAs) between GSA and DHS/

reporting of an investigation; the letting of a contract; or the issuance of a

ICE/FPS. DHS/ICE/FPS conducts a pre-employment name check through the

grant, license, or other benefit to the extent that the information is relevant

National Crime Information Center (NCIC), Interstate Identification Index (III),

and necessary to a decision;

To the Office of Personnel Management (OPM), the Office of Management

Citizenship & Immigration Status Check, and a wanted person file; and forwards

and Budget (OMB), or the Government Accountability Office (GAO) when the

your fingerprints to the FBI to conduct a national fingerprint background check.

information is required for program evaluation purposes;

The FBI provides the FBI Identification Record which lists information taken from

To a Member of Congress or staff on behalf of and at the request of the

fingerprint submissions retained by the FBI in connection with arrests and, in

individual who is the subject of the record;

some instances, Federal employment, naturalization, or military service, to DHS/

10.

To an expert, consultant, or contractor of GSA in the performance of a

ICE/FPS to make a determination for unescorted physical access. DHS/ICE/FPS

Federal duty to which the information is relevant;

will transmit the access determination electronically to designated GSA officials

11.

To the National Archives and Records Administration (NARA) for records

and the temporary contractor’s company.

management purposes;

12.

To appropriate agencies, entities, and persons when (1) the Agency suspects

AUTHORIZATION AND RELEASE

or has confirmed that the security or confidentiality of information in the system

I hereby authorize the U.S. General Services Administration and other

of records has been compromised; (2) the Agency has determined that as a

result of the suspected or confirmed compromise there is a risk of harm to

authorized Federal agencies to obtain any information required from the

economic or property interests, identity theft or fraud, or harm to the security or

Federal government and/or state agencies, including but not limited to, the

integrity of this system or other systems or programs (whether maintained by

Federal Bureau of Investigation (FBI), the Defense Security Service (DSS),

GSA or another agency or entity) that rely upon the compromised information;

the U.S. Office of Personnel Management (OPM), the U.S. Department of

and (3) the disclosure made to such agencies, entities, and persons is

Homeland Security (DHS), (if applicable). This authorization is valid for one

reasonably necessary to assist in connection with GSA's efforts to respond to

year from the date this form was signed or upon termination of my affiliation

the suspected or confirmed compromise and prevent, minimize, or remedy

with the Federal Government, whichever is sooner.

such harm.

PUBLIC REPORTING BURDEN STATEMENT

I have been notified of any employer’s right to require a criminal history

Public reporting burden for this collection of information is estimated to

records check as a condition of contract employment with GSA. I

average 15 minutes per response, including the time to review instructions,

understand that I may request a copy of such records as may be available

search existing data sources, gather and maintain data needed, and

to me under the law. I understand that I have a right to challenge the

complete and review the collection of information. Send comments

accuracy and competencies of any information contained in the report. I

regarding this burden estimate or any other aspects of this collection of

also understand that this information will be treated as privileged and

information, including suggestions for reducing this burden, to Personnel

confidential information. Case files are handled under the procedures for

Security Requirements Division (CPR), General Services Administration,

safeguarding records.

Washington DC 20405.

I release any individual, including records custodians, any component of

FINAL DETERMINATION ON YOUR ACCESS PROVISIONING

the U.S. Government or the individual State Criminal History Repository

supplying information, from all liability for damages that may result on

Final determination on granting unescorted physical access to GSA-

account of compliance, or any attempts to comply with this authorization.

controlled facilities is the responsibility of the U.S. Department of

This release is binding, now and in the future, on my heirs, assigns,

Homeland Security, Immigrations and Customs Enforcement, Federal

associates, and personal representative(s) of any nature. Copies of this

Protective Service (DHS/ICE/FPS). You may be provided the opportunity

authorization that show my signature are as valid as the original release

personally to explain, refute, or clarify any information before a final

signed by me.

decision is made.

AUTHORIZATION AND RELEASE AND CERTIFICATION

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD

YOU HAVE PROVIDED ALL REQUESTED INFORMATION FULLY AND

RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS

CORRECTLY.

DATE

SIGNATURE

I declare under penalty of perjury that

the statements made by me on this

form are true, complete and correct.

GENERAL SERVICES ADMINISTRATION

PAGE 2 OF 2

GSA 850 (REV. 12/2009)

Form Gsa 850 - Temporary Contractor Information Worksheet - 2012 Page 2

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