Standard Form 86 Security Investigation Data for Sensitive Position
Document date 17 December 1970
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Id: Cooper-Part-26:039-043
Subject: Cooper Files: Cooper-Part-26:039-043 Document: Standard Form 86 Security Investigation Data for Sensitive Position Id: Cooper-Part-26:039-043 Page: https://cooper.theunsolved.net/documents/Cooper-Part-26%3A039-043 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
A person reads every report. Corrections are made by hand, to the data — titles, dates, names, which pages belong together — never to the scans, and they can take a while to appear.
FBI 164-81, Vault Part 26 pp. 39–43 (DB Cooper-7192–7196), Form, dated 17 Dec 1970 — cooper.theunsolved.net/documents/Cooper-Part-26%3A039-043
Standard Form 86 AUGUST 1964 U.S. CIVIL SERVICE COMMISSION (F.P.M. CHAPTER 7X) 86-76
SECURITY INVESTIGATION DATA FOR SENSITIVE POSITION
CASE SERIAL NO. (CSC use only)
INSTRUCTIONS.--Prepare in triplicate, using a typewriter. Fill in all items. If the answer is "No" or "None," so state. If more space is needed for any item, continue under item 28.
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1. FULL NAME LAST NAME FIRST NAME MIDDLE NAME [redacted - b6 Per BOC]
(Initials and abbreviations of full name are not acceptable. If no middle name, show "(NMN)"; if initials only, show "(io given, or middle name)")
OTHER NAMES USED. (Maiden name, names by former marriages, former names changed legally or otherwise, aliases, nicknames, etc. Specify which, and show dates used) [redacted - b7C Per BOC]
2. DATE OF BIRTH [redacted - b6 Per BOC]
3. PLACE OF BIRTH [redacted - b7C Per BOC]
4. [X] MALE [ ] FEMALE
5. HEIGHT: 70" WEIGHT: 200 COLOR EYES: Bl COLOR HAIR: Br
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6. [ ] SINGLE [X] MARRIED [ ] WIDOW(ER) [ ] DIVORCED
7. IF MARRIED, WIDOWED, OR DIVORCED, GIVE FULL NAME AND DATE AND PLACE OF BIRTH OF SPOUSE OR FORMER SPOU[SE] WIFE'S MAIDEN NAME. GIVE DATE AND PLACE OF MARRIAGE OR DIVORCE. [redacted - b6 Per BOC] [redacted - b7C Per BOC]
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8. DATES AND PLACES OF RESIDENCE. (If actual places of residence differ from the mailing addresses, furnish and identify both and go back to January 1, 1937. Continue under item 28 on other side if necessary.)
Begin with present
FROM TO NUMBER AND STREET CITY STAT[E] 11/01/70 Present b6 Per BOC 07/68 10/70 05/68 07/68 09/67 04/68 11/66 09/67 04/66 11/66 04/65 04/66 03/65 04/65 01/64 03/65 11/63 01/64 11/60 11/63 10/60 11/60
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9. [X] BY BIRTH [ ] NATURALIZED ALIEN REGISTRATION NO. DATE, PLACE, AND COURT [X] U.S. CITIZEN CERT. NO. PETITION NO. [ ] DERIVED-PARENTS CERT. NO(S). [ ] ALIEN REGISTRATION NO. NATIVE COUNTRY DATE AND PORT OF ENTRY
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10. EDUCATION. (All schools above elementary.) NAME OF SCHOOL ADDRESS FROM (Year) TO (Year) DEGREES [redacted - b6 Per BOC] [redacted - b7C Per BOC]
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11. THIS SPACE FOR FBI USE. (See also item 29.)
12. SOCIAL SECURITY NUMBER [redacted - b6 Per BOC]
13. MILITARY SERVICE (Past or present) SERIAL NO. BRANCH OF SERVICE (If none, give grade or rating (Army, Navy, Air Force, etc.) FROM (Yr.) TO (Yr.) at separation) [redacted] Marine Corps 1951 1970 b6 Per BOC
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DB Cooper-7192
14. HAVE YOU EVER BEEN DISCHARGED FROM [redacted] ED FORCES UNDER OTHER THAN HONORABLE CONDI[TIONS] . ☐YES ☒NO. (If answer is "Yes," give details in item [redacted])
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15. EMPLOYMENT. (List ALL employment dates starting with your present employment. Give both month and year for all dates. Show ALL dates and addresses when unemployed. Give name under which employed if different from name now used.)
FROM TO NAME OF EMPLOYER (Firm or agency) ADDRESS TYPE OF WORK REASON FOR LEAVING AND SUPERVISOR (Full name, if known) (Where employed) 11/01/70 Present Unemployed b6 Per BOC
[remainder of employment table is blank]
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15. HAVE YOU EVER BEEN DISCHARGED (FIRED) FROM EMPLOYMENT FOR ANY REASON? ☐YES ☒NO.
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17. HAVE YOU EVER RESIGNED (QUIT) AFTER BEING INFORMED THAT YOUR EMPLOYER INTENDED TO DISCHARGE (FIRE) YOU FOR ANY REASON? ☐YES ☒NO. (If your answer to 16 or 17 above is "Yes" give details in item 23. Show the name and address of employer, approximate date, and reasons in each case. This information should agree with the statements made in item 15--EMPLOYMENT.)
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18. HAVE YOU EVER BEEN ARRESTED, TAKEN INTO CUSTODY, HELD FOR INVESTIGATION OR QUESTIONING, OR CHARGED BY ANY LAW ENFORCEMENT AUTHORITY? (You may omit: (1) Traffic violations for which you paid a fine of $30 or less; and (2) anything that happened before your 16th birthday. All other incidents must be included, even though they were dismissed or you merely forfeited collateral.) ☐YES ☒NO.
IF YOUR ANSWER IS "YES," GIVE FULL DETAILS BELOW:
DATE CHARGE PLACE LAW ENFORCEMENT AUTHORITY ACTION TAKEN
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(SIGNATURE AND TITLE OF AUTHORIZED AGENCY OFFICIAL) [redacted] U.S. GOVERNMENT PRINTING OFFICE: 1964-O-755-147 /19-C DB Cooper-7193
CASE SERIAL NO. LCSC use only
19. HAVE YOU EVER HAD A NERVOUS BREAKDOWN OR HAVE YOU EVER HAD MEDICAL TREATMENT FOR A MENTAL CONDITION? ☐ YES ☒ NO. (If your answer is "Yes," give details in item 28.)
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20. FOREIGN COUNTRIES VISITED (SINCE 1930). (Exclusive of military service.) COUNTRY DATE LEFT U.S.A. DATE RETURNED U.S.A. PURPOSE None
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21. ARE YOU NOW, OR HAVE YOU EVER BEEN, A MEMBER OF THE COMMUNIST PARTY, U.S.A., OR ANY COMMUNIST OR FASCIST ORGANIZATION? ☐ YES ☒ NO.
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22. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY FOREIGN OR DOMESTIC ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP, OR COMBINATION OF PERSONS WHICH IS TOTALITARIAN, FASCIST, COMMUNIST, OR SUBVERSIVE, OR WHICH HAS ADOPTED OR SHOWS, A POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES, OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS? ☐ YES ☒ NO.
23. IF YOUR ANSWER TO QUESTION 21 OR 22 ABOVE IS "YES," STATE THE NAMES OF ALL SUCH ORGANIZATIONS, ASSOCIATIONS, MOVEMENTS, GROUPS, OR COMBINATIONS OF PERSONS AND DATES OF MEMBERSHIP. IN ITEM 28 OR ON A SEPARATE SHEET TO BE ATTACHED TO AND MADE A PART OF THIS FORM, GIVE COMPLETE DETAILS OF YOUR ACTIVITIES THEREIN AND MAKE ANY EXPLANATION YOU DESIRE REGARDING YOUR MEMBERSHIP OR ACTIVITIES.
NAME IN FULL ADDRESS FROM TO OFFICE HELD
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24. MEMBERSHIP IN OTHER ORGANIZATIONS. (List all organizations in which you are now a member or have been a member, except those which show religious or political affiliations.) (If none, so state.)
NAME IN FULL ADDRESS TYPE FROM TO OFFICE HELD b6 Per BOC None
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25. RELATIVES. (Parents, spouse, divorced spouse, children, brothers, and sisters, living or dead. Name of spouse should include maiden name and any other names by previous marriage. If person is dead, state "dead" after relationship and furnish information for other columns as of time of death.)
RELATION NAME IN FULL YEAR OF BIRTH ADDRESS COUNTRY OF BIRTH PRESENT CITIZENSHIP Father Mother Wife Daughter Daughter
Ex-Wife
Brother Sister b6 Per BOC b7C Per BOC
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DB Cooper-7194
26b REFERENCES (Name three persons, not [redacted] ss or employers, who are aware of your qualifica [redacted] d fitness.) [redacted] NAME IN FULL | E ADDRESS | BUSINESS A[redacted]SS | YEARS KNOWN [redacted] b6 Per BOC b7C Per BOC [redacted] 5
26b. CLOSE PERSONAL ASSOCIATES. (Name three persons, such as friends, schoolmates or colleagues, who know you well.) NAME IN FULL | HOME ADDRESS | BUSINESS ADDRESS | YEARS KNOWN [redacted] b6 Per BOC b7C Per BOC 25 25 25
27. TO YOUR KNOWLEDGE, HAVE YOU EVER BEEN THE SUBJECT OF A FULL FIELD OR BACKGROUND PERSONAL INVESTIGATION BY ANY AGENCY OF THE FEDERAL GOVERNMENT [X] YES [] NO. (If your answer is "Yes," show in item 28, (1) the name of the investigating agency (2) the approximate date of investigation, and (3) the level of security clearance granted, if known.)
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22. SPACE FOR CONTINUING ANSWERS TO OTHER QUESTIONS. (Show item numbers to which answers apply. Attach a separate sheet if there is not #27 National Agency Checks in 1952 & 1965 Final Secret issued in 1966 #8 from [redacted] to [redacted] number and street [redacted] city [redacted] sta[redacted] b6 Per BOC
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29 REPORT OF INFORMATION DEVELOPED. (This space reserved for FBI use) DATE:
[blank space]
Before signing this form check back over it to make sure you have answered all questions fully and correctly. CERTIFICATION. I CERTIFY that the statements made by me on this form are true, complete and correct to the best of my knowledge, and belief, and are made in good faith. b6 Per BOC False statement on this form b7C Per BOC is punishable by law. 17 Dec, 1970 (DATE) (SIGNATURE—Sign original and first carbon copy)
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INFORMATION TO BE FURNISHED BY AGENCY
INSTRUCTIONS TO AGENCY: See Federal Personnel Manual Chapter 736 and FPM Supplement 296-31, Appendix A, for details on when this form is required and how it is used. If this is a request for investigation before appointment, insert "APPL" in the space for Date of Appointment and show information about the proposed appointment in the other spaces for appointment data. The original and the first carbon copy should be signed by the applicant or appointee. Submit the original and the unsigned carbon copy of the form, Standard Form 87 (Fingerprint Chart), and any investigative information about the person received on voucher forms or otherwise, to the United States Civil Service Commission, Bureau of Personnel Investigations, Washington, D.C., 20415. If this is a request for full field security investigation, submit these forms to the attention of the Division of Reimbursable In- vestigations; if this is a request for preappointment national agency checks, submit these forms to the attention of the Control Section.
RETAIN THE CARBON COPY OF STANDARD FORM 86 (SIGNED BY THE APPLICANT OR APPOINTEE) FOR YOUR FILES
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DATE OF APPOINTMENT | TYPE OF APPOINTMENT | CIVIL SERVICE REGULATION NUMBER OR | TITLE OF POSITION AND GRADE OR | [] EXCEPTED | OTHER APPOINTMENT AUTHORITY | SALARY Applicant | [X] COMPETITIVE (Include indefinite and tem- | S.F. Reg. USCSC | Customs Security | porary types of competitive appointments.) | ltr dated 11/23/70 | Officer GS-4
DEPARTMENT OR AGENCY | DUTY STATION | SEND RESULTS OF PREAPPOINTMENT CHECK TO: Bureau of Customs | Portland, | Bureau of Customs b6 Per BOC R[redacted] | [redacted]n | Office of Security b7C Per BOC | | 2100 K Street N.W. THIS | | Washington, D.C. 20226 D[redacted] [redacted] oner (Personnel) (SIGNATURE AND TITLE OF AUTHORIZED AGENCY OFFICIAL)
US GOVERNMENT PRINTING OFFICE, 1964-O-755-147 #18-E
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DB Cooper-7195
#8 From to number and street city state b6 Per BOC [REDACTED - large blank box] #6 [REDACTED - smaller blank box] b6 Per BOC
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DB Cooper-7196