1
The City of New York
Department of Investigation
180 Maiden Lane, 16
th
Floor
New York, NY 10038
(212) 825-5911
Financial Background Investigation Questionnaire
You are required to complete this questionnaire (in addition to the Background Investigation Questionnaire
or Supplemental Background Investigation Questionnaire) only if your appointing entity has determined
that you meet the criteria for which it is permissible for the Department of Investigation (DOI) to review and
report your consumer credit history (pursuant to NYC Administrative Code §§ 8-102 and 8-107; 47 Rules
of the City of New York §§ 2-01 and 2-05).
Your Terms and Conditions of Appointment will not be approved unless you provide all information
requested and cooperate fully with this background investigation. If you fail to do so, you may incur
disciplinary action, including the termination of your employment or removal from your appointment.
Department o
f Investigation (DOI) background investigations are detailed and thorough; information you
provide will be verified during the investigation. A false statement or intentional omission made in this
questionnaire, or in connection with this background investigation, may result in the imposition of
disciplinary penalties, including but not limited to termination of employment or removal from appointment,
disqualification from future employment or appointment, and criminal prosecution.
Your complet
ed Financial Background Investigation Questionnaire is not a public document and cannot
be obtained through a Freedom of Information Act request. However, upon request your questionnaire
may be provided for use in another government agency’s background investigation, or for the purposes of
administrative action (e.g., internal investigations, disciplinary proceedings) by your agency, the City’s
Office of Administrative Trials and Hearings, the Conflicts of Interest Board, or others.
DOI recomm
ends that you make a photocopy of this completed questionnaire for your personal
records, and for reference in completing any future DOI Financial Background Investigation
Questionnaires.
I have read and I understand this information. Initial and date: ___________
For DOI Use Only:
Candidate’s Name
____________________________
Phone Number
_________________
Investigator
____________________________
Interview Date
_________________
Supervisor
____________________________
Review Date
_________________
FBIQ (March 2020)
□ Check here if additional information is provided in the addendum. 2
DEPARTMENT OF INVESTIGATION
FINANCIAL BACKGROUND INVESTIGATION QUESTIONNAIRE
INSTRUCTIONS
This questionnaire must be typed, or completed in blue or black ink.
Every question must be answered completely and accurately.
Do not leave any question blank. Indicate “N/A” (not applicable) if a question does not apply
to you.
If you need more space to answer a question, use the addendum provided. Check the box at
the bottom of the page on which the question appears, and note in the addendum the question
and page number.
This questionnaire is an affidavit. Upon completion, it must be signed and sworn to before a
Notary Public or Commissioner of Deeds.
I have read and I understand these instructions. Initial and date: ____________________
PERSONAL INFORMATION
1.
Full Name
Last Name
First Name
Middle Name
Jr., II, etc.
□ N/A □ N/A
2.
Date of Birth
Month
Day
Year
3.
Place of Birth
City
State
Country
□ Check here if additional information is provided in the addendum. 3
ASSETS
Bank, Brokerage, and Investment Accounts
4.
List all U.S. bank, brokerage, and investment accounts (including but not limited to
savings, checking, money market, mutual funds, cryptocurrency,
certificates of
deposit, and credit union accounts).
Include all accounts on which you or your spouse or domestic partner is named
as a primary, secondary, or joint account holder, or for which either of you is
an authorized signatory. If you have more than one account with an institution,
list each account separately.
□ N/A
Name of Financial
Institution
Name(s) of Account Holder(s) Account Type
Approximate
Current Balance
□ Check here if additional information is provided in the addendum. 4
.Retirement Accounts and Annuities
5.
List all U.S. retirement accounts (including but not limited to IRAs, deferred
compensation, Keoghs, pension, and 401(k) accounts), as well as annuities, owned
by you or your spouse or domestic partner.
□ N/A
Name of Institution Name(s) of Account Holder(s) Account Type
Approximate
Current Value
Bonds, Notes, and Bills
6.
Provide the total market value of all U.S. government-issued bonds, notes, and bills
(e.g., savings bonds, municipal bonds, treasury notes) held by you or your spouse or
domestic partner.
□ N/A
Total Approximate Market Value of Holdings:
□ Check here if additional information is provided in the addendum. 5
Stocks and Other Bonds
7.
List all U.S. stocks that are not held in a brokerage account, and all bonds that are
not government-issued, held by you or your spouse or domestic partner.
□
N/A
Name of
Institution/Issuer
Name(s) of Account
Holder(s)
Number of
Shares or
Face Value
of Bonds
Approximate
Current
Market Value
Dividend or
Interest Income
Earned Prior
Calendar Year
Foreign Financial Interests
8.
Provide details below if you or your spouse or domestic partner has direct control or
ownership of foreign financial businesses, foreign bank accounts, or other foreign
financial interests (including but not limited to stocks, annuities, retirement accounts,
government-issued bonds, notes, and bills, investments, or ownership of corporate
entities). Exclude U.S.-based funds or accounts managed through an employer.
□ N/A
Type of Foreign Financial Interest
Name(s) of Account Holder(s)
Value (U.S. Dollars)
□ Check here if additional information is provided in the addendum. 6
Foreign Financial Interests (Controlled by Someone Else)
9.
Provide details below if you or your spouse or domestic partner has a foreign interest
that someone else controls on your behalf (including but not limited to stocks,
annuities, retirement accounts, government-issued bonds, notes, and bills,
investments,or ownership of corporate entities). Exclude U.S.-based funds or
accounts managed through an employer.
□ N/A
Type of Foreign
Financial Interest
Name(s) of Account
Holder(s)
Name of Person
Who Controls the
Financial Interest
Your
Relationship to
Them
Value (U.S.
Dollars)
□ Check here if additional information is provided in the addendum. 7
Money Owed to You or Your Spouse or Domestic Partner
10.
If you or your spouse or domestic partner is owed money (e.g., personal loans,
promissory notes), provide details below.
□
N/A
Debtor #1
Full name of debtor
Relationship to you
Home address
Date of loan (month/year)
Reason for loan
Original amount of loan
Repayment terms
Payment frequency:
Interest rate:
Date loan is due (month/year)
Approximate outstanding balance
Debtor #2 □ N/A
Full name of debtor
Relationship to you
Home address
Date of loan (month/year)
Reason for loan
Original amount of loan
Repayment terms
Payment frequency:
Interest rate:
Date loan is due (month/year)
Approximate outstanding balance
□ Check here if additional information is provided in the addendum. 8
Debtor Employment/Business with the City of New York
11.
Provide details below if a debtor listed in response to Question 10 is employed by
the City of New York (or any of its agencies) or does business with the City of
New York (or any of its agencies).
Doing business with the City includes
receiving funds from the City, having
contracts with the City, providing materials or services to the City, having matters
pending before the City, or holding any franchise, license, permit, or other privilege
from the City.
□ N/A
Debtor’s Full Name
Debtor’s City Agency
or Nature of Business with the City
Debtor’s Title/Position
Pension or Retirement Benefits
12.
If you are collecting a pension or retirement benefit, provide details below. Include
New York City retirement systems (e.g., NYCERS, TRS) and any government or
private retirement system or pension plan.
□ N/A
Name of Retirement or Pension Fund
Total Received Annually
Interests in Businesses, Firms, Entities, or Other Organizations
13.
List any interest, direct or indirect, which you or your spouse or domestic partner has
in a business, firm, partnership, entity, or other organization, other than through
ownership of publicly-traded stocks or bonds. Include all ownership interests,
whether or not income has been received from them.
□ N/A
Name of Entity Nature of Interest
Date
Acquired
(Month/Year)
Approximate
Current Market
Value of
Interest
Income Earned
Prior Calendar
Year
□ Check here if additional information is provided in the addendum. 9
Ownership of Real Property in the United States
14.
List any residence, including your current primary residence, or item of real
estate located in the U.S., or in a U.S. territory or commonwealth, in which you or
your spouse or domestic partner has
an ownership interest, whether direct or
indirect. Include all real property (e.g., houses, condominiums,
shares in
cooperative apartments, commercial properties, investment properties).
□ N/A
U.S. Property #1
Property address
Type:
□
House
□
Condominium
□
Co-op Apartment
□
Other: ______________________
Date purchased (month/year)
Name of seller
Approximate acquisition cost
Approximate current value
Annual maintenance cost (e.g., for co-op or condo)
□
N/A
Total annual rental income received
□
N/A
Time spent there (e.g., three nights per week, weekends, holidays)
□ Check here if additional information is provided in the addendum. 10
U.S. Property #2
□
N/A
Property address
Type: □ House □ Condominium □ Co-op Apartment □ Other: ______________________
Date purchased (month/year)
Name of seller
Approximate acquisition cost
Approximate current value
Annual maintenance cost (e.g., for co-op or condo)
□
N/A
Total annual rental income received
□
N/A
Time spent there (e.g., three nights per week, weekends, holidays)
U.S. Property #3
□
N/A
Property address
Type: □ House □ Condominium □ Co-op Apartment □ Other: ______________________
Date purchased (month/year)
Name of seller
Approximate acquisition cost
Approximate current value
Annual maintenance cost (e.g., for co-op or condo)
□
N/A
Total annual rental income received
□
N/A
Time spent there (e.g., three nights per week, weekends, holidays)
□ Check here if additional information is provided in the addendum. 11
Ownership of Real Property in Foreign Countries
15.
List any residence or item of real estate located in a foreign country (not in the U.S.
or in a U.S. territory or commonwealth) in which you or your spouse or domestic
partner has an ownership interest, whether direct or indirect. Include all real property
(e.g., houses, condominiums, shares in cooperative apartments, commercial
properties, investment properties).
□ N/A
Foreign Property #1
Property address
Type: □ House □ Condominium □ Co-op Apartment □ Other: ______________________
Date purchased (month/year)
Name of seller
Approximate acquisition cost
Approximate current value
Annual maintenance cost (e.g., for co-op or condo)
□
N/A
Total annual rental income received
□
N/A
Time spent there (e.g., three nights per week, weekends, holidays)
Foreign Property #2
□
N/A
Property address
Type:
□
House
□
Condominium
□
Co-op Apartment
□
Other: ______________________
Date purchased (month/year)
Name of seller
Approximate acquisition cost
Approximate current value
Annual maintenance cost (e.g., for co-op or condo)
□
N/A
Total annual rental income received
□
N/A
Time spent there (e.g., three nights per week, weekends, holidays)
□ Check here if additional information is provided in the addendum. 12
Other Sources of Income
16.
List all income you or your spouse or domestic partner has received within the past
12 months from any source not
addressed by your previous answers in this
questionnaire (including but not limited to inheritances, gambling winnings, alimony,
child support, and public assistance).
□ N/A
Source of Income
Name(s)
of Income Recipient(s)
Approximate Amount Received
□
one-time sum
□ total received annually
□
one-time sum
□
total received annually
□
one-time sum
□
total received annually
Personal Property
17.
List each individual item of personal property (including but not limited to jewelry, art
and collectibles, motor vehicles, watercraft, and aircraft) with a value of $5,000 or
more, which is held directly or indirectly by you or your spouse or domestic partner.
Do not include personal clothing or household furniture.
□ N/A
Description of Item
Year of Acquisition
Value
□ Check here if additional information is provided in the addendum. 13
LIABILITIES
Credit Cards
18.
Provide details below for all credit cards that list you or your spouse or domestic
partner as a primary or secondary account holder and that carry a monthly
balance of $5,000 or more. Include bank, retail, travel, and entertainment credit
cards.
□ N/A
Name of Issuer
or Bank
Type of Card (e.g., American
Express, Discover, MasterCard,
Visa)
Account Holder(s)
Current
Balance
□ Check here if additional information is provided in the addendum. 14
Mortgages and Loans
19.
List each creditor to whom you or your spouse or domestic partner is indebted for
$5,000 or more (whether secured or unsecured).
Include
personal loans, student loans, mortgages, home equity loans,
car loans/leases, and any other debts or obligations made, guaranteed, or co-signed
by either you or your spouse or domestic partner.
□ N/A
Creditor #1
Name of creditor (if creditor is a person, also state your relationship to them)
Nature of debt
Nature of security (e.g., house, car, unsecured)
Date incurred (month/year)
Original amount of debt
Length of loan (years)
Interest rate
Payment frequency
Amount of each payment
Year loan is due
Approximate outstanding balance
Creditor #2 □
N/A
Name of creditor (if creditor is a person, also state your relationship to them)
Nature of debt
Nature of security (e.g., house, car, unsecured)
Date incurred (month/year)
Original amount of debt
Length of loan (years)
Interest rate
Payment frequency
Amount of each payment
Year loan is due
Approximate outstanding balance
□ Check here if additional information is provided in the addendum. 15
Creditor #3
□
N/A
Name of creditor (if creditor is a person, also state your relationship to them)
Nature of debt
Nature of security (e.g., house, car, unsecured)
Date incurred (month/year)
Original amount of debt
Length of loan (years)
Interest rate
Payment frequency
Amount of each payment
Year loan is due
Approximate outstanding balance
Creditor #4 □ N/A
Name of creditor (if creditor is a person, also state your relationship to them)
Nature of debt
Nature of security (e.g., house, car, unsecured)
Date incurred (month/year)
Original amount of debt
Length of loan (years)
Interest rate
Payment frequency
Amount of each payment
Year loan is due
Approximate outstanding balance
□ Check here if additional information is provided in the addendum. 16
Creditor #5
□
N/A
Name of creditor (if creditor is a person, also state your relationship to them)
Nature of debt
Nature of security (e.g., house, car, unsecured)
Date incurred (month/year)
Original amount of debt
Length of loan (years)
Interest rate
Payment frequency
Amount of each payment
Year loan is due
Approximate outstanding balance
Creditor #6 □
N/A
Name of creditor (if creditor is a person, also state your relationship to them)
Nature of debt
Nature of security (e.g., house, car, unsecured)
Date incurred (month/year)
Original amount of debt
Length of loan (years)
Interest rate
Payment frequency
Amount of each payment
Year loan is due
Approximate outstanding balance
□ Check here if additional information is provided in the addendum. 17
Non-Commercial Creditors’ Associations with the City of New York
20.
This question does not apply to commercial lending institutions (e.g., commercial
banks, credit unions, mutual companies). If a non-commercial lender/creditor listed
in response to Question 19 is employed by the City of New York (or any of its
agencies), or if they do business with the City of New York (or any of its agencies),
provide details below.
Doing business with the City
includes receiving funds from the City, having
contracts with the City, providing materials or services to the City, having matters
pending before the City, or holding any franchise, license, permit, or other privilege
from the City.
□ N/A
Full Name of Creditor (Institution or Person)
Creditor’s City Agency
or Nature of Business with the City
Outstanding Judgments
21.
List all judgments entered against you or your spouse or domestic partner that are
outstanding (except tax judgments and liens, which should be disclosed in
Question 22). Include documentation with your background paperwork.
□ N/A
Name of Creditor and Court
Where Judgment Was Filed
Date of Judgment
(Month/Year)
Garnishment
Yes/No
Original
Amount
Amount
Outstanding
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Check here if additional information is provided in the addendum. 18
Tax Judgments and Liens
22.
List all tax judgments and/or liens entered against you or your spouse or domestic
partner within the past seven years, even if they have been satisfied.
Candidates undergoing a background investigation must satisfy all
outstanding tax judgments and liens with the appropriate tax authority, either
by making full payment or by entering into a payment agreement.
Include documentation of your full payment with your background paperwork
(e.g., receipt, bank statement, canceled check, certificate of release of federal tax
lien, satisfaction of judgment), or a copy of your
current installment payment
agreement and documentation of your three most recent payments.
□ N/A
Name of Tax
Authority
Name of
Responsible
Taxpayer
Date of
Judgment
(Month/Year)
Original
Amount
Amount
Outstanding
Date Satisfied
(Month/Year)
□ Not satisfied
□
Not satisfied
□ Not satisfied
□
Not satisfied
□
Not satisfied
□ Check here if additional information is provided in the addendum. 19
Money Owed to Tax Authorities
23.
Provide details below if you or your spouse or domestic partner owes money
(not including tax judgments or liens) to federal or state tax authorities.
Include documentation (e.g., installment payment agreement)
with your
background paperwork.
□ N/A
Name of Tax
Authority
Name of
Responsible
Taxpayer
Tax Year
Amount
Outstanding
Details of
Most Recent
Payment
Anticipated
Date of
Satisfaction
Date
Amount
Date
Amount
Tax Audits
24.
If a tax authority has audited any tax return filed by you or your spouse or domestic
partner within the past five years, provide details below. This does not include tax
assessments or tax bills.
Include
a copy of the tax authority’s findings, or your most recent
correspondence with the tax authority, with your background paperwork.
□ N/A
Name of Tax
Authority
Name of Audited
Taxpayer
Tax
Year
Findings of Audit
Interest or
Penalties
Assessed
and/or Paid
Outcome or
Status
□ Check here if additional information is provided in the addendum. 20
Bankruptcies
25.
Provide details below if you or your spouse or domestic partner has filed a petition
under any chapter of the bankruptcy code, or has been the subject of a bankruptcy
or reorganization proceeding, within the past 10 years. Include
with your
background paperwork a copy of the bankruptcy discharge documents and
list of creditors (chapter 7), or a copy of the chapter 11 or 13 plan.
□ N/A
Bankruptcy #1
Name of filer
Bankruptcy petition type
□
Chapter 7
□
Chapter 11
□
Chapter 13
Name of court
Date filed (month/year)
Date of discharge or acceptance of plan (month/year)
Total debt discharged for chapter 7
Terms of repayment for chapter 11 or chapter 13 (include total repayment amount; length of plan in
months or years; frequency of payments; and current balance)
Detailed explanation of the reason for filing for bankruptcy
Bankruptcy #2 □ N/A
Name of filer
Bankruptcy petition type
□
Chapter 7
□
Chapter 11
□
Chapter 13
Name of court
Date filed (month/year)
Date of discharge or acceptance of plan (month/year)
Total debt discharged for chapter 7
Terms of repayment for chapter 11 or chapter 13 (include total repayment amount; length of plan in
months or years; frequency of payments; and current balance)
Detailed explanation of the reason for filing for bankruptcy
□ Check here if additional information is provided in the addendum. 21
Evictions
26.
If you have ever been evicted from a property you owned or rented, or at which you
resided, provide details below.
□
N/A
Property Address
Date of
Eviction
(Month/Year)
Amount Owed at Time
of Eviction
Current Balance
□
N/A
□
N/A
Reason for Eviction:
Child Support Payment Obligations
27.
List any child support payments you are currently obligated to make.
□
N/A
Name of Recipient
(e.g., Custodial
Parent, Child Support
Agency)
Name of Child
Date
Commenced
(Month/Year)
Frequency
and Amount of
Payments
Most Recent
Payment
Frequency
Date
Amount
Amount
Frequency
Date
Amount
Amount
□ Check here if additional information is provided in the addendum. 22
Court-Ordered Child Support Payments
28.
If you have been ordered by a court to make child support payments, provide details
below.
□
N/A
Name and Location of Court
(e.g., Supreme Court of the State of
New York County, Family Court of
the State of New York)
Date of Most
Recent Order of
the Court
(Month/Year)
Case Name
and Index Number
Frequency
and Amount of
Payments
Frequency
Amount
Frequency
Amount
Outstanding Balances Due on Child Support Payments
29.
If you have an outstanding balance due on any child support payment, provide
details below.
□
N/A
Amount Owed
Date of Last Child
Support Payment
Reason Child Support is Outstanding
□ Check here if additional information is provided in the addendum. 23
Civil Litigation and Lawsuits
30.
If you have been involved as a plaintiff, defendant, or respondent in any civil litigation
or lawsuit commenced within the past 10 years, provide details below.
□
N/A
Title of Action
and Date Commenced
(Month/Year)
Status or Outcome
of Litigation
Amount You Owed
or Were Awarded
Date Paid
(Month/Year)
□
Owed
□
Awarded
□
N/A
□
Owed
□
Awarded
□
N/A
□
Owed
□
Awarded
□
N/A
Administrative Proceedings
31.
If you have been involved as a party to, or have been the subject of, an administrative
proceeding (e.g., disciplinary proceeding
, censure, Conflicts of Interest Board
enforcement action) commenced within the past 10 years, provide details below.
Do not include any Equal Employment Opportunity matters, or matters you
have reported as a whistleblower.
□ N/A
Disposition
(Month/Year)
Government
Agency Involved
Fine or Penalty
Imposed
Status of Fine
or Penalty
□
No fine/penalty
□
N/A
□
No fine/penalty
□
N/A
□
No fine/penalty
□
N/A
□ Check here if additional information is provided in the addendum. 24
Government Benefits
32.
Provide details below if you have ever been informed of an overpayment of, or if you
have been requested or required to repay, a federal, state, or local
government-issued benefit or payment (e.g., public assistance, food stamps,
unemployment insurance, workers’ compensation, Medicaid, Social Security, public
pension, public housing/Section 8 rent subsidy).
□ N/A
Benefit-Issuing
Entity
Date of
Overpayment
(Month/Year)
Date of
Notification of
Overpayment
(Month/Year)
Amount Owed Status
□ Satisfied
□ Outstanding
□ Satisfied
□ Outstanding
Financial Arrangements (Potential Conflicts of Interest)
33.
List any financial arrangements that may present a potential conflict of interest with
your City employment.
□
N/A
Description of the
Financial
Arrangement
Name of Other
Involved Party
Basis of Potential
Conflict of Interest
Your Plan to Resolve the
Potential Conflict of Interest
(e.g., advice from COIB,
resignation, divestiture,
recusal)
25
CERTIFICATION AND SIGNATURE
This Questionnaire must be signed and sworn to by you before a
Notary Public or Commissioner of Deeds.
I, ____________________________________, being duly sworn, state that
I have read and I understand all of the questions and answers contained in the
foregoing 24 pages of this questionnaire and the _____ page(s) of the addendum
that I have attached hereto; that I have supplied full and complete information in
answer to each question herein to the best of my knowledge, information and belief;
and that all information I have supplied is true.
I further understand that a false statement or intentional omission made in
this report or in connection with this background investigation may result in the
imposition of disciplinary penalties, including but not limited to termination of
employment or removal from appointment, disqualification from future employment
or appointment, and criminal prosecution.
___________________________________
Candidate’s Signature
State of
________________
County of
________________
Subscribed and sworn to before me this _______ day of _____________________, 20 _______
__________________________________
Notary Public or Commissioner of Deeds
ADDENDUM
(make additional copies of this blank page if needed)
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Last Name: ___________________ Last four digits of SSN: __________ Date: __________
