1
The City of New York
Department of Investigation
180 Maiden Lane, 16
th
Floor
New York, NY 10038
(212) 825-5911
Background Investigation Questionnaire
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 of Invest
igation (DOI) background investigations are detailed and thorough; information
you provide will be verified during the investigation.
A false statement or int
entional 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 completed Backgr
ound 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 recommends that yo
u make a photocopy of this completed questionnaire for your
personal records, and for reference in completing any future DOI Background Investigation
Questionnaires.
I have read and I understand this information. Initial and date: ___________
For DOI Use Only:
Candidate’s Name
____________________________
Phone Number
_________________
Investigator
____________________________
Review Date
_________________
Supervisor
____________________________
Review Date
_________________
BIQ (March 2020)
□ Check here if additional information is provided in the addendum.
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DEPARTMENT OF INVESTIGATION
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.
Other Names
Used
If you have ever used or been known by another name, including a
maiden name or alias, provide details below.
□
N/A
Full Name
Dates Used
(Month/Year)
Reason Used
to
to
3.
Date of Birth
Month
Day
Year
4.
Place of Birth
City
State
Country
□ Check here if additional information is provided in the addendum.
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5. Social Security Number
6.
Additional Social
Security Number
If you have ever used or been issued a Social Security
number other than the one listed in response to Question 5,
provide details below.
□ N/A
Additional Social Security Number
Dates Used (Month/Year)
Reason Used/Issued
to
Authorization to Work in the United States
7.
□
I am legally authorized to work in the United States.
□ I am not legally authorized to work in the United States.
Provide details below, including your plan to resolve the matter, and whether your agency has
been notified. Include copies of any correspondence you have sent to or received from
the United States government in your effort to resolve this matter.
Details
8.
Contact Information
Enter your e-mail address(es) and phone number(s).
Work E-mail Address
□ N/A
Personal E-mail Address
□ N/A
Primary Work Phone Number
□
Desk
□
Cell
□ N/A
Secondary Work Phone Number
□ Desk □ Cell
□ N/A
Primary Personal Phone Number
□ Home □ Cell
Secondary Personal Phone Number
□
Home
□
Cell
□ N/A
□ Check here if additional information is provided in the addendum.
4
Social Media Accounts and Personal Websites
9.
Provide the information below for all social media accounts, personal websites, and blogs used
or maintained by you or your spouse or domestic partner.
Type of Site
Your Screen Name (e.g., username,
profile name, handle)
Spouse or Domestic Partner’s
Screen Name (e.g., username,
profile name, handle)
Blog
URL:
□ N/A
URL:
□ N/A
Facebook
□ N/A
□ N/A
Instagram
□ N/A
□ N/A
LinkedIn
□ N/A
□ N/A
Personal Website
URL:
□ N/A
URL:
□ N/A
Reddit
□ N/A
□ N/A
Snapchat
□ N/A
□ N/A
Tumblr
□ N/A
□ N/A
Twitter
□ N/A
□ N/A
YouTube
□ N/A
□ N/A
Other (specify)
□ N/A
□ N/A
10.
Current Marital Status (Select One)
□
Single (Never Married)
Domestic Partner applies to persons who have a
registered domestic partnership pursuant
to New
York City Administrative Code Section 3-241, or a
domestic partnership registered in accordance
with
New York City Mayoral Executive Order No. 123,
dated August 7, 1989, or New York City Mayoral
Executive Order No. 48, dated January 7,
1993.
□
Married
□
Domestic Partner
□
Legally Separated
□
Divorced
□
Widowed
□ Check here if additional information is provided in the addendum.
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Spouse or Domestic Partner
11.
If you have a spouse or domestic partner, provide their information below.
□ Spouse □
Domestic Partner
□ N/A
Name
(Last, First)
Social Security
Number
Date of Birth
(Month/Day/Year)
Date of Marriage
or Registration
(Month/Day/Year)
Maiden Name (if applicable):
Spouse or Domestic Partner’s Address
□ Same as my current primary residence (if different, provide address below)
Street Address
City, State, and ZIP Code
Spouse or Domestic Partner’s Employment
Name and Address of Business or Employer
Job Title
□
Full-time
□ Part-time
□ Retired
□ N/A
Former Spouse or Domestic Partner
12.
If you have been legally separated, divorced, or widowed, or have a terminated
domestic partnership, provide details below.
Include a copy of your separation agreement, divorce decree, or termination
statement with your background paperwork.
□ N/A
□ Legally Separated □ Divorced □ Widowed □ Terminated Domestic Partnership
Spouse or Domestic Partner’s Name
(Last, First)
Date of Birth
(Month/Day/Year)
Date of Action or Death
(Month/Day/Year)
□ Check here if additional information is provided in the addendum.
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Family Members
13.
List all of the following living family members: mother and father (including step), brothers and
sisters (including half and step), children (including step), and dependents. For each family
member, check all boxes that apply. Use the addendum to list additional family members.
If you indicate “Identity Unknown,” leave the remaining details for that person blank.
Parent
□ Mother □ Father □ Stepmother □ Stepfather □ Identity Unknown □ N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Parent
□
Mother
□
Father
□
Stepmother
□
Stepfather
□
Identity Unknown
□
N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Parent
□
Mother
□
Father
□
Stepmother
□
Stepfather
□
Identity Unknown
□
N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Parent
□ Mother □ Father □ Stepmother □ Stepfather □ Identity Unknown □ N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Child
□ Son □ Daughter □ Stepson □ Stepdaughter □ N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
□ Check here if additional information is provided in the addendum.
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Child
□
Son
□
Daughter
□
Stepson
□
Stepdaughter
□
N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Child
□ Son □ Daughter □ Stepson □ Stepdaughter □ N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Sibling
□
Brother
□
Sister
□
Stepbrother
□
Stepsister
□
Half-brother
□
Half-sister
□
Identity Unknown
□
N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Sibling
□
Brother
□
Sister
□
Stepbrother
□
Stepsister
□
Half-brother
□
Half-sister
□
Identity Unknown
□
N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Sibling
□
Brother
□
Sister
□
Stepbrother
□
Stepsister
□
Half-brother
□
Half-sister
□ Identity Unknown □ N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
Dependent
Relationship to you: ______________________ □ N/A
Name (Last, First)
Date of Birth
Street Address
City, State, and ZIP Code
□
Check here if additional information is provided in the addendum.
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Family Members Employed by the City of New York
14.
Provide details below if any person listed in response to Question 13 is employed
by the City of New York (or any of its agencies), or is employed as a director,
officer, principal, or partner of any organization (non-City entity) that 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
Full Name (Last, First)
and Relationship to You
City Agency
or Non-City Entity
Title/Position
□
Check here if additional information is provided in the addendum.
9
RESIDENCE INFORMATION
If the position for which you are being investigated requires New York City residency, you
must comply with such requirement within the time period established for your agency.
Residence History
15.
Starting with your current primary address and working backward, list the full address of every
place you have resided during the past 10 years.
For purposes of this question, reside means living or having lived in such residence on a
regular and consistent basis by staying or having stayed in such residence for a total of at
least 30 nights (consecutive or nonconsecutive) in a calendar year.
Dates (Month/Year)
Street Address
City, State, and ZIP Code
to Present
to
to
to
to
to
to
Time Spent Outside New York State
16.
List each period of time (if not already listed in response to Question 15) you
have lived somewhere other than New York State for three months or more since
the age of 18. If you were attending school during that time, include the name of
the institution.
□ N/A
Dates (Month/Year)
City, State (and School)
to
to
to
to
□
Check here if additional information is provided in the addendum.
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17. Mailing Address
List your mailing address if different from your current
primary residence listed in response to Question 15.
□
N/A
Street Address or P.O. Box
City, State, and
ZIP Code
Began Using
(Month/Year)
Reason Used
18. Voter Registration Address
□ Same as Primary Residence □ Not Registered
Street
City, State, and ZIP Code
County
Owner of Current Primary Residence
19.
Provide the name of the owner of your current primary residence and indicate whether the
owner 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), 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.
Name of Owner(s)
Relationship to You
(e.g., self, spouse or domestic
partner, landlord, parents)
City Agency and Job Title,
or Nature of Involvement with City
□
N/A
Select One: □ Own □ Rent □ Other
If you selected “Other,” provide the details of your living arrangement and your relationship to the
property owner:
□
Check here if additional information is provided in the addendum.
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Additional Property
20.
List any other property owned or rented by you or your spouse or domestic partner,
or any property at which you reside, other than your current primary residence (e.g.,
property that generates rental income, vacation home, the residence of a family
member or significant other).
For purposes of this question, reside means living or having lived in such residence
on a regular and consistent basis by staying or having stayed in such residence for
a total of at least 30 nights (consecutive or nonconsecutive) in a calendar year.
□ N/A
Property Address
Name of Owner and Your
Relationship to Them
Amount of Time Spent There
(e.g., three nights per week,
weekends, holidays)
Property Violations
21.
For all properties owned by you or your spouse or domestic partner, provide details
of any outstanding violations issued by a government entity, including but not
limited to building, environmental, sanitation, and fire departments.
□ N/A
Property Address
Date Issued
(Month/Year)
Issuing Entity and
Violation/Summons
Number
Violation Details
□
Check here if additional information is provided in the addendum.
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PROPERTY RECORD
Residents and Tenants
22.
List every person, whether related to you or not, who has resided at any time in
the past 12 months in your current primary residence, or in any other property
owned or rented by you or your spouse or domestic partner.
Include your spouse or
domestic partner and children, even if you have
already listed them in response to other questions.
For purposes of this question, reside means living or having lived in such residence
on a regular and consistent basis by staying or having stayed in such residence for
a total of at least 30 nights (consecutive or nonconsecutive) in a calendar year.
□ N/A
Full Name
(Last, First)
Relationship
(e.g., spouse,
child, tenant,
friend)
Property
Address
Dates of
Residence in the
Past 12 Months
(Month/Year)
to
□ Same as my primary residence
to
□ Same as my primary residence
to
□ Same as my primary residence
to
□ Same as my primary residence
to
□ Same as my primary residence
to
□ Same as my primary residence
□
Check here if additional information is provided in the addendum.
13
Residents and Tenants Employed by the City of New York
23.
Provide details below if any person listed in response to Question 22 is employed
by the City of New York, does business with the City of New York (or any of its
agencies), or is employed as a director, officer, principal, or partner of any
organization that does business with the City of New York
(or any of its
agencies).
Do not include any person whom you have already li
sted in response to
Question 14.
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
(Last, First)
City Agency and Job Title,
or Nature of Involvement
with City
Annual Rent
□ N/A
□ N/A
□ N/A
DRIVING AND VEHICLE RECORD
Driver’s Licenses and Permits
24.
List all valid driver’s licenses or permits issued to you.
□ N/A
Name on License
or Permit
License or Permit
Number
Address
(City, State, and
ZIP Code)
Issuing Entity
(e.g., New York State
Department of Motor Vehicles)
Pursuant to New York State Vehicle Traffic Law § 250, you may possess only one U.S. driver’s
license at a time, and within 30 days of becoming a New York State resident, you must
surrender your out-of-state driver’s license.
□
Check here if additional information is provided in the addendum.
14
Driver’s License Records
25.
If a driver’s license issued to you has been revoked or suspended within the past
10 years, provide details below.
□
N/A
Date of
Revocation or
Suspension
(Month/Year)
State Where
License Was
Issued
State Where
License Was
Revoked or
Suspended
Reason or Basis
for Revocation or
Suspension
Date of
Reinstatement
(Month/Year) or
Current Status
Registered Vehicles
26.
List all vehicles, including but not limited to cars, trucks, vans, motorcycles, and
recreational vehicles (e.g., mopeds, ATVs, boats), registered to or leased by you or
your spouse or domestic partner, or in the name of a business in which you or your
spouse or domestic partner has an ownership interest.
□ N/A
Name on Registration Address on Registration
License Plate
Number
Make
and Model
Vehicle
Type
Pursuant to New York State Vehicle Traffic Law § 250, within 30 days of becoming a New York
State resident, you must obtain a New York State registration for vehicle(s) maintained within
the State.
□
Check here if additional information is provided in the addendum.
15
Parking Violations
27.
List any outstanding summonses for parking violations in this or any other
jurisdiction.
□
N/A
Date Issued
(Month/Year)
City, State Where
Issued
Violation or Charge License Plate Number
Traffic Infractions
28.
List any outstanding summonses or citations for violations of traffic regulations or
laws in this or any other jurisdiction.
□
N/A
Date Issued (Month/Year)
City, State Where Issued
Violation or Charge
FIREARM LICENSE/PERMIT RECORD
Firearm Licenses or Permits
29.
If you have a license or permit to possess or carry a firearm, provide details below.
Include a copy of the front and back of your
license or permit with your
background paperwork.
□ N/A
Issuing
Body
License/Permit
Number and Type
Date Issued
(Month/Year)
Expiration Date
(Month/Year)
□
Check here if additional information is provided in the addendum.
16
Firearm License or Permit Records
30.
If you have ever had a license or permit to possess or carry a firearm revoked or
suspended, or if you have ever had an application for a license or permit to possess
or carry a firearm denied, or if you have ever had a firearm confiscated, provide
details below.
Include copies of documentation or correspondence from the licensing
authority or confiscating agency with your background paperwork.
□ N/A
Licensing Authority
or Confiscating Agency
Action (e.g.,
suspended,
confiscated)
Date
of Action
(Month/Year)
Reason Status
Firearms
31.
List all firearms you own or possess, or to which you have access.
□
N/A
Make, Model,
and Type
(e.g., Glock 19
handgun)
Owner (e.g., self,
employer, friend)
Location of Firearm
(Property Address)
Method of Safeguarding (for
firearms you own or possess)
□ N/A
□
N/A
□ N/A
□ N/A
□ N/A
□
Check here if additional information is provided in the addendum.
17
ACADEMIC AND LICENSING RECORD
Academic Degrees
32.
List all high schools, technical schools, colleges, universities, graduate schools, and
professional schools you have attended. If you have
received a High School
Equivalency Diploma, provide details in Question 33.
If you have received a degree from a foreign educational institution, include
with your background paperwork a copy of the degree, a certified translation,
and an evaluation from a foreign education evaluation service that has been
approved by the City’s Department of Citywide Administrative Services.
□ N/A
Name of Institution
Location
City, State, and
Country
Dates Attended
(Month/Year)
Type of
Degree
Date Awarded
(Month/Year)
to
□ N/A
to
□ N/A
to
□ N/A
to
□ N/A
to
□ N/A
to
□ N/A
High School Equivalency Diploma
33.
If you have received a High School Equivalency Diploma, also known as a General
Equivalency Diploma (GED) or Test Assessing Secondary Completion
, provide
details below.
If you took the High School Equivalency Test or Test Assessing Secondary
Completion
in New York State before 1982, include a copy of your diploma
with your background paperwork.
□ N/A
Name of Accrediting Body or Institution
(e.g., New York State Education
Department)
Location of Test
(City, State)
Date Awarded
(Month/Year)
□
Check here if additional information is provided in the addendum.
18
Professional Licenses
34.
List all professional licenses that have ever been issued to you (e.g., architect,
attorney, certified public accountant, engineer, medical doctor, notary public, nurse,
physician’s assistant, real estate salesperson, security guard
, social worker,
teacher).
□ N/A
Type of License
Issuing
Entity
Identification
Number
Date Issued
(Month/Year)
Expiration Date
(Month/Year)
Professional License Records
35.
Provide details below if any of the following have occurred in connection with
a professional license issued to you:
You have surrendered or been required to surrender a license.
You have been disciplined (e.g., censured, fined, penalized, placed on probation,
reprimanded, suspended).
You have had a license canceled, denied, suspended, or revoked.
You are the subject of any current investigations or pending charges.
Include copies of documentation or correspond
ence from the licensing
authority with your background paperwork.
□ N/A
Type of License
Date of Action
(Month/Year)
Type of Action
Reason
for Action
Disposition
□
Check here if additional information is provided in the addendum.
19
EMPLOYMENT
Employment History
36.
Provide your employment history, starting with your current position (Employment #1). Go
back 10 years (but not prior to your 18
th
birthday). Include
a copy of your resume or
curriculum vitae with your background paperwork; however, you must also provide
your employment history below.
Include all employment with the City of New York (not just within the past 10 years).
Include self-employment, freelance work, military service, internships (paid or unpaid), and
each period of unemployment for three or more months.
If you were employed as a consultant or temporary worker, list the name of the consulting
firm or staffing agency under “Name of employer.” If you were placed at a City agency, add
the name of the agency as follows: “Name of staffing company (name of City agency).”
If you were self-employed, state the business conducted. Include with your background
paperwork proof of income for the most recent five years,
or less, as applicable
(e.g., Form W-2, Form 1099, Form 1040 Schedule C, Form 1065 Schedule K-1).
If you were unemployed
for three or more months, state how you were financially
supported during that time (e.g., family support, public assistance, savings, severance pay,
student loans, unemployment insurance).
Employment #1 (current or most recent position)
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
□
Check here if additional information is provided in the addendum.
20
Employment #2 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
Employment #3 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
□
Check here if additional information is provided in the addendum.
21
Employment #4 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
Employment #5 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
□
Check here if additional information is provided in the addendum.
22
Employment #6 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
Employment #7 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
□
Check here if additional information is provided in the addendum.
23
Employment #8 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
Employment #9 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
□
Check here if additional information is provided in the addendum.
24
Employment #10 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
Employment #11 □
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
Your most recent title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Compensation and Status
□ Paid □ Unpaid
□ Full-time □ Part-time
Type of separation (e.g., voluntary
resignation, termination, layoff)
□
Unemployed (if unemployed, state
your source of financial support)
□ Check here if additional information is provided in the addendum.
25
Employment Records
37. Provide details below if any of the following ever occurred during your
employment history, including internships (whether paid or unpaid).
You were disciplined in any manner (for example: demoted, fined, penalized,
reprimanded, suspended), for any type of misconduct (for example: absence/lateness
issues, violations of internal policies, or violations of Equal Employment
Opportunity policies, including sexual harassment).
You were laid off.
You were terminated.
You were asked to resign.
You resigned to avoid being fired or disciplined, or after being told that you would be fired or
disciplined.
You resigned while aware that there was an allegation of misconduct pending against you
(including by not limited to the examples of workplace misconduct listed above).
You separated by mutual agreement following allegations of unsatisfactory
performance.
□ N/A
Employment Record #1
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
□
Full-time
□
Part-time
Your title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Date of action (month/year)
Description of what occurred
Outcome
You must provide details of any of these types of events whether or not your former employer
would disclose the information, and without regard to any non-disclosure or non-disparagement
agreement that might prevent the employer from disclosing the information.
□ Check here if additional information is provided in the addendum.
26
Employment Record #2
□
N/A
Name of employer
Street address
City, State, and ZIP Code
Dates of employment (month/year)
From: To:
□
Full-time
□
Part-time
Your title
Supervisor’s name and title
Supervisor’s phone number
Supervisor’s e-mail address
Date of action (month/year)
Description of what occurred
Outcome
Investigations for Government Positions
38.
If you have ever been investigated for a position (e.g., employment, board or
commission appointment, consulting and/or temporary position, internship,
fellowship) with a government agency, including DOI, provide details below.
□ N/A
Date Initiated
(Month/Year)
Agency Name
Position for Which You
Were Investigated
Outcome or Status
of Investigation
□ Check here if additional information is provided in the addendum.
27
Government or Civil Service Employment Records
39.
If you have ever been disqualified or barred from appointment to a position with a
government agency, or if you have ever been disqualified for employment in a civil
service position, provide details below.
Include a copy of the agency’s findings with your background paperwork.
□ N/A
Date of Action
(Month/Year)
Agency Name Position
Reason for Disqualification
or Debarment
MILITARY SERVICE RECORD
Military Service History
40.
Provide details below if you serve, or have served, in any branch of the U.S. military
(e.g., Air Force, Army, Coast Guard, Marine Corps, Navy, Space Force, National
Guard).
Include with your background paperwork a copy of your unedited or undeleted
military discharge document (e.g., DD Form 214, DD Form 256, NGB Form 22).
□ N/A
Branch of Service
Dates of Service
(Month/Year)
Type of Discharge (if you did not receive an
Honorable Discharge, explain the circumstances)
to
Military Service Records
41.
For the military service listed in response to Question 40, provide details below if you
have ever been subject to administrative corrective measures (e.g., reprimand,
censure, administrative withholding of privileges) or nonjudicial punishment
(Captain’s or Admiral’s Mast, Office Hours, Article 15, etc.), or fo
und guilty or
convicted by court-martial, under the Uniform Code of Military Justice.
□ N/A
Date of Action
(Month/Year)
Description of What Occurred Outcome
□ Check here if additional information is provided in the addendum.
28
COURT, INVESTIGATIVE, AND GOVERNMENT RECORD
Select one of the following then proceed to the appropriate question number:
□ I am a peace officer. If this applies to you, proceed to Question 42.
□ I am a police officer. If this applies to you, proceed to Question 42.
□ I am being appointed to a position with one of the law enforcement agencies listed below, and I
am not a peace officer or police officer. If this applies to you, proceed to Question 43.
□ I am not being appointed to a position with one of the law enforcement agencies listed below,
and I am not a peace officer or police officer. If this applies to you, proceed to Question 44.
New York City Law Enforcement Agencies
Board of Correction
Business Integrity Commission
Civilian Complaint Review Board
Commission to Combat Police Corruption
Department of Correction
Department of Investigation
Department of Probation
Mayor’s Office of Criminal Justice
Police Department
□ Check here if additional information is provided in the addendum.
29
Court Record (Peace Officer/Police Officer)
42.
Complete this section only if you are a peace officer or police officer.
Instructions:
Disclose all
offenses, including violations, misdemeanors, and felonies, or similar
offenses in other states, for which you have been convicted in any jurisdiction.
Disclose all
summonses (other than traffic summonses), desk appearance tickets
(DATs), arrests, and indictments.
Disclose all criminal proceedings that were terminated in your favor (e.g., declined to
prosecute; dismissal or acquittal of charges).
Disclose all matters that resulted in an adjournment in contemplation of dismissal.
Disclose material that may have been sealed, set aside under federal or state law, as
well as youthful offender adjudications.
Discl
ose all Uniform Code of Military Justice offenses for which you were charged.
Do not disclose any charge for the possession of 25 grams or less of marihuana that
occurred prior to August 28, 2019.
Do not disclose dispositions from family court.
A guilty plea, guilty verdict, or plea of nolo contendere is a conviction even if, upon
sen
tencing, you were never imprisoned, only paid a fine, were conditionally or
unconditionally discharged, or received a Certificate of Relief from Disabilities.
Include an
original Certificate(s) of Disposition with your background paperwork, along
with any Certificate(s) of Relief from Disabilities.
□
N/A (After reading the instructions above, I have no information to disclose.)
Date of Charge
(Month/Year)
Date of Conviction
(Month/Year)
Disposition
□
Not convicted
□ Not convicted
□ Not convicted
□ Check here if additional information is provided in the addendum.
30
Court Record (Law Enforcement Agency)
43.
Complete this section only if you are being appointed to a position with one of the law
enforcement agencies listed on page 28.
I
nstructions:
Disclose all
offenses, including violations, misdemeanors, and felonies, or similar
offenses in other states, for which you have been convicted in any jurisdiction.
D
isclose material that may have been sealed, set aside under federal or state law, as
well as youthful offender adjudications.
Do not disclose any charge for the possession of 25 grams or less of marihuana that
occurred prior to August 28, 2019.
Do not disclose dispositions from family court.
A guilty plea, guilty verdict, or plea of nolo contendere is a conviction even if, upon
sentencing, you were never imprisoned, only paid a fine, were conditionally or
unconditionally discharged, or received a Certificate of Relief from Disabilities.
In
clude an original Certificate(s) of Disposition with your background paperwork, along
with any Certificate(s) of Relief from Disabilities.
□
N/A (After reading the instructions above, I have no convictions to disclose.)
Date of Charge
(Month/Year)
Date of Conviction
(Month/Year)
Disposition
□ Check here if additional information is provided in the addendum.
31
Court Record (Other Agency)
44. Complete this section only if you are you are not a peace officer or police officer, and you are
not being appointed to a position with one of the law enforcement agencies listed on page 28.
Instructions:
Disclose all misdemeanor or felony convictions (or similar offenses in other states) in
any jurisdiction.
Disclose all convictions for the following violations: driving while ability is impaired, and
loitering for the purpose of engaging in prostitution, or equivalent convictions in other
states.
Do not disclose any charge for the possession of 25 grams or less of marihuana that
occurred prior to August 28, 2019.
Do not disclose dispositions from family court.
Do not disclose youthful offender adjudications. You are not considered a youthful
offender simply because of your age at the time of the offense; only a specific court
finding determines youthful offender status. If you are unsure whether you were
determined to be a youthful offender, review your records or contact the court.
Do not disclose convictions that have been sealed, expunged, or set aside under
federal or state law.
A guilty plea, guilty verdict, or plea of nolo contendere is a conviction even if, upon
sentencing, you were never imprisoned, only paid a fine, were conditionally or
unconditionally discharged, or received a Certificate of Relief from Disabilities.
Include an original Certificate(s) of Disposition with your background paperwork, along
with any Certificate(s) of Relief from Disabilities.
□
N/A (After reading the instructions above, I have no convictions to disclose.)
Date of Charge
(Month/Year)
Date of Conviction
(Month/Year)
Disposition
□ Check here if additional information is provided in the addendum.
32
Probation, Parole, or Supervised Release
45.
If you are on probation, parole, or supervised release, provide details below.
□ N/A
Start Date
(Month/Year)
Anticipated End
Date
(Month/Year)
Supervising Authority and
Type (Probation, Parole,
Supervised Release)
Terms of Probation, Parole,
or Supervised Release
Orders of Protection
46.
Provide details of any order of protection that has ever been entered against you.
Include a copy of the order(s) of protection with your background paperwork.
□
N/A
Court name and location
Provide the specific directions in the order
of protection (e.g., follow custody orders,
pay child support, stay away from spouse
and children, not have a gun)
Name of the protected person(s) and your
relationship to them
Date issued (month/year)
Date of expiration (month/year)
Bond or Surety
47.
Provide details below if you have ever been refused or denied a cash bond or surety
bond (e.g., bail bond, business surety bond, public official bond), or if you have ever
had a bond revoked or suspended.
□ N/A
Bond/Surety Issuer
Name and Address
Date of Action
(Month/Year)
Reason
Refused, Denied, Revoked, or Suspended
□
Check here if additional information is provided in the addendum.
33
Pending Matters
48.
Provide details of any summonses (other than traffic summonses), desk appearance
tickets (DATs), arrests, or indictments that are pending against you.
□
N/A
Date of Charge
(Month/Year)
Description of the Specific
Nature of the Offense(s)
Court Name and Address
Active Investigations
49.
Provide details below if you have been informed, or have reason to believe, that you
are currently under investigation by a federal, state, or local prosecutor, or
legislative, civil, or criminal investigative body (including DOI and its Inspectors
General), or grand jury. This does not include background investigations
conducted by DOI or another government agency.
□ N/A
Date (Month/Year)
Government Agency or Court
Matter Involved
□
Check here if additional information is provided in the addendum.
34
Government Inquiries
50.
Provide details below if you have ever been subpoenaed, called as a witness,
questioned or interviewed, or have been asked to provide testimony or documents
before a federal, state, or local prosecutor or court; a legislative, civil, regulatory, or
criminal investigative body (including DOI and its Inspectors General); or grand jury.
Do not include matters for which you testified as part of your official
employment duties.
□ N/A
Date
(Month/Year)
Government Agency or Court Matter Involved Your Role
If you were granted immunity in any form, or you entered into a consent decree, in any of the above
matter(s), please explain below:
Privilege/Contempt
51.
Provide details below if you have ever asserted the Fifth Amendment privilege
against self-
incrimination or refused to testify before a federal, state, or local
prosecutor or court, a legislative, civil, or criminal investigative body (including DOI
and its Inspectors General), or grand jury, or if you have been cited for contempt of
a court, or legislative, civil, or criminal investigative body, or grand jury.
□ N/A
Date
(Month/Year)
Government Agency or
Court
Matter Involved
□ Check here if additional information is provided in the addendum.
35
Criminal Proceedings
52.
Provide details below if you have ever been named or referred to (including as an
unindicted co-conspirator) in an indictment or other accusatory instrument, or if you
have ever been named in, or were the subject of, a search warrant or court-ordered
electronic surveillance.
□ N/A
Date
(Month/Year)
Court
(Name and Location)
Details
Criminal Associations
53.
If you have ever knowingly associated with a person, including a family member,
known or reputed to be a member or associate of an organized crime or terrorist
group, provide details below.
Do not include associations occurring during the performance of your official
employment duties.
□ N/A
Name of Person
Name of Organized
Crime or Terrorist Group
Relationship
Dates of Relationship
(Month/Year)
to
to
to
□ Check here if additional information is provided in the addendum.
36
Civil Litigation and Lawsuits
54.
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.
Do not
include bankruptcies or financial judgments.
□ N/A
Title of Action and
Date Commenced
(Month/Year)
Government
Agency or
Court
Matter Involved Your Role
Outcome or
Status
□ Check here if additional information is provided in the addendum.
37
Administrative Proceedings
55.
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
that were
unsubstantiated, or in which you were the complainant.
□ N/A
Disposition
(Month/Year)
Name of
Government Agency
or Company
Matter Involved
Outcome or
Status
Fine or Penalty
Issued Against
You
□
No fine/penalty
□
No fine/penalty
Government Benefits
56.
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)
Reason for
Overpayment
Status
□ Satisfied
□ Outstanding
□ Satisfied
□ Outstanding
□
Check here if additional information is provided in the addendum.
38
INCOME AND TAX FILING RECORD
Income Earned (New York State)
57.
List the total annual income you earned in New York State for each of the past five
years. (For the “Tax Year,” refer to the five years listed on the Federal and State Tax
Release forms included with your background investigation paperwork.) Include
income from all sources (e.g., employment; self-employment, including freelance,
consulting, and temporary work; paid internships/fellowships; rental income).
□ N/A
Tax Year Total Annual Income Earned in New York State
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
Income Earned (Other States)
58.
List the total annual income you earned in any other state(s) for the past five years.
(For the “Tax Year,” refer to the five years listed on the Federal and State Tax
Release forms included with your background investigation paperwork.) Include
income from all sources (e.g., employment; self-employment, including freelance,
consulting, and temporary work; paid internships/fellowships; rental income).
If you earned income in more than one state in a tax year, use a separate row for
each state. Use the addendum to list additional states.
□ N/A
Tax
Year
State Total Annual Income Earned
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
20____
□ No income □ Less than $15,000 □ $15,000–$50,000 □ More than $50,000
□
Check here if additional information is provided in the addendum.
39
Federal and State Tax Returns
59.
Refer to the five years listed on the Federal and State
Tax Release forms included with your background
investigation paperwork. For these five years, have you
filed your federal and state income tax returns by the due
date, or within a properly obtained extension period?
□ Yes (proceed to Question 61)
□ No (proceed to Question 60)
Federal and State Tax Returns (Late and Non-Filing Information)
60.
If you answered “No” to Question 59, complete the chart below. Use the addendum
if needed. This information is required only for the years you did not file your
federal or state income tax return(s) by the due date, or within a properly
obtained extension period. If you did not file, or were not required to file, because
you were a dependent or were unemployed, or because you earned less than the
amount required for filing, state this in the “Reason for late or non-filing” section.
□ N/A
Tax
Return
Year
State(s) in
Which You
Resided
State(s) in
Which You
Worked
Tax Returns
(Federal, State,
or Both)
Late Filing Date of
Federal Return
(Month/Year)
Late Filing Date
of State Return
(Month/Year)
20___
Reason for late or non-filing for the tax year listed above:
Tax
Return
Year
State(s) in
Which You
Resided
State(s) in
Which You
Worked
Tax Returns
(Federal, State,
or Both)
Late Filing Date of
Federal Return
(Month/Year)
Late Filing Date
of State Return
(Month/Year)
20___
Reason for late or non-filing for the tax year listed above:
Tax
Return
Year
State(s) in
Which You
Resided
State(s) in
Which You
Worked
Tax Returns
(Federal, State,
or Both)
Late Filing Date of
Federal Return
(Month/Year)
Late Filing Date
of State Return
(Month/Year)
20___
Reason for late or non-filing for the tax year listed above:
□
Check here if additional information is provided in the addendum.
40
Filing Instructions and Documentation to Satisfy the Non-Filing of Tax Returns
For any of the past five years, if you were required to file federal and/or state income tax returns
and have not done so by the due date, or within a properly obtained extension period, you are
required to file such returns promptly as instructed below.
Federal Income Tax Returns: Your federal returns can be filed electronically or submitted in person
at a local Internal Revenue Service (IRS) office (check IRS.gov for locations). If you file electronically,
provide DOI with a copy of the first page and signature page of the returns and a filing confirmation
receipt. If you submit your returns in person, provide DOI with a copy of the first page and signature
page of the returns stamped as received by the IRS.
New York State Income Tax Returns: Your New York State returns can be filed electronically or
by mail. Provide DOI with a copy of the first page and signature page of the returns, along with an
electronic filing confirmation receipt, or an official receipt from the United States Postal Service or
an authorized shipping agent.
Other State Income Tax Returns: If you have not filed your income tax returns for any other state
by the due date, or within a properly obtained extension period, file such returns in accordance with
the state’s filing guidelines. Provide DOI with a copy of the first page and signature page of the
returns, along with an electronic filing confirmation receipt, or an official receipt from the United
States Postal Service or an authorized shipping agent.
Non-Resident Employees of the City of New York
61.
As a condition of City employment, most employees who were hired by the City on
or after January 4, 1973, and who live outside of the City, must f
ile Form
NYC-1127 (pursuant to Section 1127 of the City Charter). This form calculates an
amount equal to a personal income tax on City residents, as if you were a resident
of the City. If you have not filed Form NYC-1127, and are unsure whether you are
required to do so, check with your agency’s Human Resources Department.
For all years you were required to file Form NYC-1127 and you did not file or make
the required payment(s), provide details below.
□ N/A
Tax Year Reason for Non-Filing
20____
20____
20____
□
Check here if additional information is provided in the addendum.
41
OUTSIDE ACTIVITIES
Pursuant to Personnel Order No. 88/5, management employees in mayoral agencies serving
in unclassified, exempt, or non-competitive titles, and management employees in mayoral
agencies serving provisionally in competitive titles, are not permitted to expend time or
otherwise engage in any private employment, profession, business, or other activity from
which compensation, direct or indirect, is derived, and are not permitted to serve as directors
or officers of any corporation or institution, except upon a specific determination by the New
York City Conflicts of Interest Board that such activity is not prohibited by Chapter 68 of the
New York City Charter.
Details of Your Outside Activities
62.
Provide details below if, upon your employment with or appointment to the
City of New York, you intend to:
serve as a director, officer, principal, or partner of any for-profit, not-for-profit,
or charitable corporation, institution, or other entity;
engage in any other employment, profession, business, or other activity from
which compensation, direct or indirect, will be derived, or from which you will
receive honoraria or royalties; and/or
engage in any volunteer activity (whether paid or unpaid) with a charitable,
civic, or community organization (do not include appointments to New York City
boards or commissions in this question).
□ N/A
Name of
Organization/Business
Your Position
and Job Description
Expected
Annual
Compensation
Time to be Expended (e.g.,
10 hours per month, one
semester per academic year)
If you intend to participate in any of the activities described in response to Question 62 during
your employment with or appointment to the City of New York, you must follow the guidelines
for outside activities established by your agency, board, or commission and, when
necessary, must seek advice from the City’s Conflicts of Interest Board.
□
Check here if additional information is provided in the addendum.
42
Business Relationships with the City of New York
63.
Provide details below if any organization or business listed in response to
Question 62 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
Name of Organization/Business
Nature of Involvement with the City
APPOINTMENTS TO GOVERNMENT BOARDS AND COMMISSIONS
Boards and Commissions
64.
If you serve or have served on a government board or commission, provide details
below.
□
N/A
Name of Board or Commission
and Location (City, State)
Your Position
Term of Appointment
(Month/Year)
to
to
Resignation or Removal
65.
If you have ever resigned or been removed from a government board or commission
listed in response to Question 64, provide details below.
□
N/A
Name of Board or Commission
and Location (City, State)
Resignation or Removal
(Month/Year)
Reason
If you intend to serve on a government board or commission during your employment with
or appointment to the City of New York, you must follow the guidelines for such activities
established by your agency, board, or commission and, when necessary, must seek advice
from the City’s Conflicts of Interest Board.
□
Check here if additional information is provided in the addendum.
43
ORGANIZATIONAL AFFILIATIONS
Organizations
66.
Within the past 10 years, if you have been a director, officer, principal,
partner, or trustee of an organization, or have served in a
management capacity for an organization, provide details below, then
answer Questions 67 through 74.
For this question, do not provide details of any government
employment for which you serve or have served as a manager,
director, or officer.
Organization means any firm, company, corporation, union, partnership,
joint venture, or other business entity, including not-for-
profit and
charitable entities.
Doing business with the City of New York 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 (Proceed
to Question 75)
Organization #1
Name of organization
Address of organization
City, State, and ZIP Code
Organization’s website
Dates involved with organization (month/year)
From: To:
Type of business conducted by organization
Your position and/or ownership interest
Description of your duties
During your involvement with the organization,
did it do business with or receive money from
the City of New York (or any of its agencies)? If
yes, state the City agency, the type of business
dealings, and your involvement, if any.
□ N/A
□
Check here if additional information is provided in the addendum.
44
Organization #2
□
N/A
Name of organization
Address of organization
City, State, and ZIP Code
Organization’s website
Dates involved with organization (month/year)
From: To:
Type of business conducted by organization
Your position and/or ownership interest
Description of your duties
During your involvement with the organization,
did it do business with or receive money from
the City of New York (or any of its agencies)? If
yes, state the City agency, the type of business
dealings, and your involvement, if any.
□ N/A
Organization #3 □ N/A
Name of organization
Address of organization
City, State, and ZIP Code
Organization’s website
Dates involved with organization (month/year)
From: To:
Type of business conducted by organization
Your position and/or ownership interest
Description of your duties
During your involvement with the organization,
did it do business with or receive money from
the City of New York (or any of its agencies)? If
yes, state the City agency, the type of business
dealings, and your involvement, if any.
□ N/A
□
Check here if additional information is provided in the addendum.
45
Investigation and Litigation History of the Organization(s)
67.
Provide details below if you know or believe that any organization listed in response
to Question 66 is, or has been, the subject of an investigation or a party to litigation
concerning activities that occurred during your time with that organization
(but no more than 10 years ago). This includes investigations
or litigation
conducted by a federal, state, or local prosecutor, or a legislative, civil, or criminal
investigative body (including DOI and its Inspectors General).
□ N/A
Name of
Organization
Government
Agency or Court
Conducting Inquiry
Date of Inquiry
(Month/Year)
Subject Matter
and Your
Involvement
Outcome or
Status
City of New York Litigation Involving the Organization(s)
68.
Provide details below if any organization listed in response to Question 66 has
been a plaintiff, defendant, or respondent in litigation involving the City of New York
(or any of its agencies) during your time with that organization (but no more
than 10 years ago).
□ N/A
Name of
Organization
Date of Action
(Month/Year)
City Agency
Subject Matter
and Your
Involvement
Outcome or
Status
□
Check here if additional information is provided in the addendum.
46
City of New York Administrative Proceedings Against the Organization(s)
69.
Provide details below if any organization listed in response to Question 66 has
been a party to, or has been the subject of, an administrative proceeding involving
the City of New York (or any of its agencies) during your
time with that
organization (but no more than 10 years ago).
□ N/A
Name of
Organization
Date of Action
(Month/Year)
City Agency
Subject Matter
and Your
Involvement
Outcome or
Status
Government Agency Action Against the Organization(s)
70.
Provide details below if any organization listed in response to Question 66 has
been suspended, debarred, disqualified, or found not responsible, or has had a
prequalification denied or revoked, or has otherwise been declared ineligible to bid
on a contract, by any government agency, including the City of New York (or any of
its agencies), during your time with that organization (but no more than 10
years ago).
□ N/A
Name of Organization
Date of Action
(Month/Year)
Government
Agency Involved
Action
Taken
Reason for
Action
□
Check here if additional information is provided in the addendum.
47
Bankruptcy Filings by the Organization(s)
71.
Provide details below if any organization listed in response to Question 66 filed for
bankruptcy, or was the subject of a bankruptcy or reorganization proceeding, during
your time with that organization (but no more than 10 years ago).
□ N/A
Petition Filed
by
Court
Filed
(Month/Year)
Discharged
(Month/Year)
Total Debt
Discharged
Basis for Filing
Failure of the Organization(s) to File Tax Returns
72.
Provide details below if any organization listed in response to Question 66 failed
to file all required federal, state, and local business tax returns, or failed to file by the
due date or within a properly obtained extension period, during your time with that
organization (but no more than 10 years ago).
□ N/A
Name of
Organization
Tax
Year(s)
Type of Tax Return and
Name of Tax Authority
Reason(s) for the
Late or Non-Filing
Outcome or
Status
□
Check here if additional information is provided in the addendum.
48
Tax Judgments or Liens Against the Organization(s)
73.
If any organization listed in response to Question 66 has tax judgments and/or
liens that have not been satisfied, or owes money to a tax authority, and these debts
were incurred during your time with that organization (but no more than 10
years ago), provide details below.
□ N/A
Name of
Organization
Tax
Authority
Tax
Year(s)
Date of
Judgment or Lien
(Month/Year)
Amount
Status (e.g.,
payment plan)
Original
Outstanding
Original
Outstanding
Original
Outstanding
Tax Audits of the Organization(s)
74.
Provide details below if any tax return filed by an organization listed in response to
Question 66 has been the subject of an audit by a tax authority during your time
with that organization (but no more than 10 years ago).
Include
a copy of the tax authority’s findings with your background
paperwork.
□ N/A
Name of
Organization
Tax
Year(s)
Tax Authority
Conducting
Audit
Findings of Audit
(Interest and Penalties
Assessed and/or Paid)
Outcome or
Status
□
Check here if additional information is provided in the addendum.
49
POLITICAL PARTY POSITIONS
Pursuant to Personnel Order No. 88/5, management employees in mayoral agencies serving
in unclassified, exempt, or non-competitive titles, or serving provisionally in competitive
titles, are not permitted to serve as officers of any political party or political organization or
as members of any political party committee, including political party district leader (however
designated). In addition, a deputy mayor, agency head, or other public servant charged with
substantial policy discretion may not be a member of the national or state committee of a
political party, and may not serve as an assembly district leader of a political party, or serve
as the chair or as an officer of the county committee or county executive committee of a
political party. See City Charter Section 2604(b)(15).
Details of Your Political Party Positions
75.
Provide details below if you are a member, officer, or chair of a political party
committee, or if you are an officer or leader of a political party or political
organization.
□ N/A
Name of Political
Organization
Title or Position Held
Term of Office
(Month/Year)
Date of Intended
Resignation
(Month/Year)
to
□
I do not intend to resign
to
□
I do not intend to resign
If you hold or intend to hold a political position during your employment with or appointment
to the City of New York, you must follow the guidelines for such activities established by your
agency, board, or commission and, when necessary, must seek advice
from the City’s
Conflicts of Interest Board.
Reports or Statements Open to Public Inspection
76.
Provide details below if you have ever been involved in an activity, such as a
political campaign, in which you were required to file reports or statements which
are open to public inspection, either for yourself or on behalf of another party.
□ N/A
Type of Materials Filed Reason for Filing
Date Filed
(Month/Year)
Location Where
Filed
□
Check here if additional information is provided in the addendum.
50
Public Office
77.
If you have ever been elected or appointed to public office, provide details below.
□ N/A
Title of Office Government Body
Location
(City, State)
Term of Office
(Month/Year)
to
to
Public Office Records
78.
If you have ever been disciplined or removed (e.g., censured, expelled, recalled,
impeached) from any public office listed in response to Question 77, provide details
below.
□ N/A
Government Body
and Title of Office
Type of Action
Date of Action
(Month/Year)
Reason for Action
and Outcome
□
Check here if additional information is provided in the addendum.
51
ADDITIONAL INFORMATION
Gifts
79.
Provide details if, within the past 12 months, you or your spouse or domestic partner
has received a gift from a person, entity, or donor who is employed by the City of
New York, or who does business with the City of New York.
Gift means anything of value for which a person pays nothing or less than fair market
value. A gift may be in the form of money, service, forgiveness of debt, travel,
entertainment, hospitality, a promise, a loan, a discount, or any other form. This
includes gifts of securities or real estate, as well as wedding gifts (except from a
relative).
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
Name
of Gift Giver
Name(s)
of Gift Recipient(s)
Gift Giver’s City
Agency or Nature of
Business with the
City
Description
of Gift
Value
of Gift
□
Check here if additional information is provided in the addendum.
52
Potential Conflicts of Interest
80.
Provide details of any potential conflicts of interest that may not have been fully
addressed by your previous answers in this background questionnaire.
□
N/A
Details of Potential Conflict
Plan to Resolve the Conflict (e.g., advice from
COIB, resignation, divestiture, recusal)
Potential Issues
81.
Provide details of any fact, issue, or other circumstance not covered in this
background questionnaire, which may be an issue or concern regarding your
appointment or employment with the City of New York.
□ N/A
Details
53
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 52 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: __________
