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Federal Investigative Services

Federal Investigations Notice

Attachment to FIN 01-13
Special Agreement Check (SAC)

OFI FORM 86C
U.S. Office of Personnel Management
September 2001 - Investigations Service

Agency Agreement Number

OPM USE ONLY

OPM Codes

Case Number

AGENCY USE ONLY (COMPLETE ITEMS 1 THROUGH 14 USING INSTRUCTIONS FROM THE BACK)

1. SUBJECT'S FULL NAME

2. DATE OF BIRTH

Last Name

First Name

Middle Name (Suffix)

Month

Day

Year

3. PLACE OF BIRTH (Use the two letter code for the State)

4. SOCIAL SECURITY NUMBER

City

County

State

Country

5. OTHER NAMES USED AND DATES WHEN USED

Name

From

Month Year

Name

From

Month Year

Name

From

Month Year

Name

From

Month Year

SEX (Mark one box)

Male
Female

SPECIAL AGREEMENT CODES

POSITION TITLE

9. SON

10. SOI

11. OPAC-ALC Number

12. Accounting Data

OTHER INFORMATION REQUIRED BY AGREEMENT

Date of Prior Investigation: ______/______/__________

Type of Prior Investigation: [ ] SSBI [ ] SSBI-PR [ ] Other ____________

Month Day Year (indicate type)

Please indicate relation code in block below and complete the necessary data.

20 - Spouse 21 - Cohabitant

RELATION CODE __________

NAME:

LAST ___________________________________FIRST___________________________

MIDDLE____________________SUFFIX__________

(eg: Jr., Sr., etc.)

Other Names Used

LAST FIRST MIDDLE FROM (M/Y) TO (M/Y) NEE (X)

__________________________ ________________________

_______________________ _____________ __________

DOB ________/_____/__________ POB CITY_____________________________

STATE__________ COUNTRY___________________

SSN________-_______-__________ CITIZENSHIP ____________________________________________

CITIZENSHIP CERTIFICATION # ________________ DATE _____/____/______

CITY____________________________________STATE____________

ALIEN REGISTRATION #_________________________________ DATE _____/____/______

CITY______________________________________STATE_________

Name and Title of Requesting Official

Signature of Requesting Official

Telephone Number

( )

Date

INSTRUCTIONS FOR COMPLETING OFI FORM 86C
GENERAL: Agencies use this form to request limited investigations, or checks, of persons in positions for which there is a special agreement with OPM that permits and specifies alternative procedures to meet investigative requirements. Complete all items on this form according to your agreement with OPM and using information obtained from the person to be checked or from documents provided by the person. THIS FORM MUST BE TYPED. Submit this form and any other documentation specified in the written agreement to: OPM-FIPC BOYERS, PA 16018
INSTRUCTIONS FOR SPECIFIC ITEMS
1	The subject's full name must be given. If the subject is a "Jr.", "Sr.", "III", etc., enter the abbreviation in the space for suffix after the middle name. If the subject has initials only, enter each initial in the appropriate box. If the subject has no middle name, enter "NMN".
2	Provide the month, day, year of subject's birth. Example: Enter June 7, 1942 as: "06/07/42".
3	Subject's place of birth: Enter full name of city/town under CITY. Under COUNTY, give county if born in United States. Using the coding shown below, provide the abbreviation for the State if born in the U.S. or its territories. Provide country of birth under COUNTRY only if not born in the United States.CODING FOR STATES, DISTRICT OF COLUMBIA, AND U.S. TERRITORIES (ITEM 3)
	Alabama	AL	Hawaii	HI	Massachusetts	MA	New Mexico	NM	South Dakota	SD
	Alaska	AK	Idaho	ID	Michigan	MI	New York	NY	Tennessee	TN
	Arizona	AZ	Illinois	IL	Minnesota	MN	North Carolina	NC	Texas	TX
	Arkansas	AR	Indiana	IN	Mississippi	MS	North Dakota	ND	Utah	UT
	California	CA	Iowa	IA	Missouri	MO	Ohio	OH	Vermont	VT
	Colorado	CO	Kansas	KS	Montana	MT	Oklahoma	OK	Virginia	VA
	Connecticut	CT	Kentucky	KY	Nebraska	NE	Oregon	OR	Washington	WA
	Delaware	DE	Louisiana	LA	Nevada	NV	Pennsylvania	PA	West Virginia	WV
	Florida	FL	Maine	ME	New Hampshire	NH	Rhode Island	RI	Wisconsin	WI
	Georgia	GA	Maryland	MD	New Jersey	NJ	South Carolina	SC	Wyoming	WY
American Samoa AS District of Columbia DC Guam GU Northern Mariana Island CM Puerto Rico PR Trust Territory TT Virgin Islands VI
4	Provide the subject's Social Security Number.
5	To the extent information is available, list all other names the subject was known by or is now using. If the subject is female, and is or was married, include maiden name, and other married names if married more than once. Provide beginning and ending dates for use of each name. Identify maiden name with "NEE".
6	Check the appropriate box to specify sex as MALE or FEMALE.
7	List the Special Agreement codes provided in the agreement with OPM.
8	Give subject's position title.
9	Give your Submitting Office Number (SON), assigned by OPM.
10	Give your Security Office Identifier (SOI), assigned by OPM.
11	Enter your agency's ALC (Agency Location Code) assigned by Treasury for use in the OPAC (On-line Payment And Collection) billing system (formerly SIBAC).
12	Your may enter your agency data for internal use. Up to 25 characters may be entered in this block. (The information you enter will be printed on documents used to close the case to your agency.) If your agency does not need this information, leave the block blank.
13	Provide any other information required by the agreement with OPM. The format and content of the data must be exactly as specified on the form.
14	Type the requestor's Name, Title, and Telephone Number, and the Date. Form must by signed by the requestor.

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U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Federal Investigative Services

Federal Investigations Notice

INSTRUCTIONS FOR COMPLETING OFI FORM 86C

INSTRUCTIONS FOR SPECIFIC ITEMS