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This questionnaire when populated with data must be emailed encryptedWHITE HOUSE COMMUNICATIONS AGENCYSECURITY SCREENING QUESTIONNAIRE (SSQ)Code:Current Clearance: SecretDate Reviewed:TSInitialsClearance Date: Projected Investigation:T5 T5-RPRIVACY ACT STATEMENT: The Authority for collecting the requested information resides in Executive Orders 10450 (Security Requirements forGovernment Employment), 11652 (Classification and Declassification of National Security Information and Material) and 9397 (Federal Agency Use ofSocial Security Numbers). The information is used in making security determinations, granting access to classified/PSD protected information and formaking personnel management decisions. Routine uses include determining the scope and coverage of a personnel security investigation, checkinginvestigative leads ensuring completeness of the investigation, and providing evaluators and/or adjudicators with basic personal history informationrelevant to security/suitability and are referenced in the SORN. Information may be disclosed to and maintained by Government agencies andadministrative personnel involved in processing security actions that evolve during the course of these determinations. When populated with data, thisquestionnaire becomes Personally Identifiable Information and must be encrypted prior to transmittal. The personal data collection will be transferredinto an approved system of record, under an Authority to Operate, granted on 10 Jul 09, under federal register chronicle 78 FR 70543, 26 Nov 13, 79 FR34299, 16 Jun 14 and maintained for up to 75 years. The SORN allowing this collection can be found at: mponent-Article-View/Article/570748/kwhc08/.LAST NAME:MI:FIRST:SSN:DATE OF BIRTH: (Month DDy Year):PLACE OF BIRTH:MOS/AFSC/RATE:BRANCH OF SERVICE:RANK/PAY GRADE:/DELAYED ENTRY DATE: BASIC ACTIVE SERVICE DATE:(0RQWK 'D\ HDU)(0RQWK 'D\ HDU)CURRENT ADDRESS:CITY:PHONE# HOME:STATE:WORK:ZIP:FAX:OFFICIAL E-MAIL ADDRESS:Have you ever applied for an assignment or been assigned to the White House Communications Agency in the past? YES NOGENERAL INFORMATION CONCERNING THIS PACKAGE: Completion of this questionnaire represents a security screening byrepresentatives of the WHCA Security Office. Please NOTE: This questionnaire covers LIFE, not simply the last 5 to 10 years of yourhistory. If favorably reviewed and you become selected for a WHCA position, additional security screening may follow, including a detailedsingle scope background investigation (SSBI) conducted by the Defense Counterintelligence and Security Agency (DCSA or DoD (EO 13869).This investigation encompasses extensive checks with appropriate law enforcement agencies, credit and financial institutions, schoolteachersand administrators, friends, neighbors, employers and other persons who know and are willing to provide information about you. Uponcompletion of all screening and investigations, a determination will be made concerning your eligibility for Presidential Support Duty (PSD). BEADVISED, falsification of this questionnaire may result in denial of PSD, denial or revocation of a security clearance or access to sensitiveinformation, or possible separation from the military service. DISREGARD ANY ADVICE YOU MAY HAVE RECEIVED CONCERNING THEWITHHOLDING OF INFORMATION. It is in your best interest to answer all questions honestly and accurately by selecting the appropriate"YES" or "NO" response. For any "YES" response, briefly explain your answer on the last page.DISCLOSURE: Voluntary; however, if WHCA does not receive this information, the will not be considered for Presidential Support Duty.(Applicant’s Signature and Date)FOR OFFICIAL USE ONLY(WHEN FILLED IN)WHCA Form 89May 2021 Previous versions are obsolete

This questionnaire when populated with data must be emailed encryptedWHCA SECURITY SCREENING QUESTIONNAIRE (SSQ)The SSQ covers LIFE (NOT simply the last 5 – 10 years)(Answering “YES” to any question(s) must be explained in theREMARKS section found at the end of this questionnaire)Loyalty and Character1. Have you ever committed or attempted to commit sabotage, subversion, espionage, treason,terrorism, or sedition?2. Have you ever knowingly established an association with a spy, terrorist, traitor, espionage agent,or representative of a foreign nation whose views or beliefs are contrary to the interests of the UnitedStates?3. Have you (or persons associated with you) ever advocated the use of force or violence tooverthrow the Government of the United States?4. Have you ever expressed (verbally or in writing) a preference or allegiance to another country?5. Have you ever publicly (in person or via social media) expressed discontent for the United StatesGovernment or President?Foreign Relationships, Travel, Assets, Associations and Relatives6. Do you have parent(s), brother(s), sister(s), spouse, children, or close friends residing outside ofthe United States (U.S. Military assignments not included)7. Do you have immediate family members who are citizens of another country, or do you maintain aclose personal relationship with a citizen of another country (i.e., cohabitate with, date, routinelycommunicate with, etc)?8. Have you made any personal/unofficial foreign travel? Did you develop any lasting relationships(continued contact via telephone, email, social networks)? Please list all personal foreign travel toinclude length and purpose.9. Do you own (fully or partially) any asset(s) in a foreign country (property, bank accounts,investments, etc.)? List any ownership of crypto-currency, marijuana and/or foreign stocks?Falsification of Information10. Have you ever mistakenly or deliberately misrepresented, falsified, or omitted significantinformation from a Personnel Security Questionnaire, a personnel qualifications statement, apersonnel security interview, or official correspondence, including your enlistment into the Military?Security Violations11. Have you ever failed to protect or safeguard classified or cryptographic information or material?12. Have you ever been counseled or charged (verbally or written) with violating a securityregulation or security procedure?13. Have you ever disclosed classified information to a person unauthorized to receive suchinformation?14. Have you ever been counseled or charged (verbally or written) with violating COMSECprocedures or IT policy?Emotional and Mental Disorders15. Do you have an illness or mental health condition of a nature which, in the opinion of a boardcertified psychiatrist, other licensed physician or a licensed clinical psychologist, causes, or maycause, a defect in judgment or reliability?16. Have you ever been counseled in the past for mental, marital, emotional, stress, behavioral, orperformance related problems?Undesirable Character Traits17. If we were to interview friends, family, supervisors, or co-workers, would any of them accuse youof engaging in any unusual conduct or behavior which would show that you are not honest, reliable,or trustworthy?18. Would anyone we interview in reference to your security clearance tell us you may be subject topressure, coercion, exploitation, or duress which may cause you to act contrary to the best interestsof national security? Such conduct or circumstances may include: criminal behavior, a pattern offinancial irresponsibility, blackmail, or violations of any military or government regulations.19. If we were to interview friends, family, former spouses, supervisors, or co-workers, would any ofthem say you have displayed poor judgment, you were unreliable, or that you are untrustworthy?FOR OFFICIAL USE ONLY(WHEN FILLED IN)WHCA Form 89May 2021 Previous versions are obsoleteYesNoYesNoYesNoYesNoYesNoYesNo2

This questionnaire when populated with data must be emailed encrypted20. Have you ever been counseled by supervisors or co-workers for poor work performance orreceived unfavorable actions based on an unsatisfactory efficiency report?21. Have you ever been forced to resign or asked to resign in lieu of termination?22. Would a check of your employment history have any derogatory comments from supervisors orco-workers?Financial Irresponsibility23. Do you currently have financial difficulties or problems meeting your financial obligations?24. Have you ever defaulted on a loan or had a debt turned over to a credit collection agency?25. Would a credit search of your records reveal late payments or financial difficulties (such as butnot limited to bankruptcy, foreclosure, repossession, etc.)?26. Have you ever failed to file your taxes? Have you ever been notified by the IRS in regards tofailing to file your taxes?27. Have you ever been charged, informally or formally, for the misuse of a Government orCorporate Credit Card?Moral Conduct28. Have you ever been involved in or suspected/accused of child molesting, adultery, rape,indecent exposure, child/spouse abuse, prostitution, sexual harassment or group sex?29. Have you participated in any conduct that could cause embarrassment to you or your family, orwhich could cause you to be blackmailed if such conduct were uncovered?30. Have the police ever come to your home or interviewed you for any reason?Record of Law Violation31. Have you ever been suspected of, accused, charged, placed on probation (to include academicprobation) or prosecuted with any law violation*, including, but not limited to:Writing bad checksFailure to pay alimony or child supportShoplifting or theftDisorderly conductMalicious mischiefBreaking and enteringDrinking underageCurfew violationAny misdemeanor or felonyYesNoYesNoYesNoYesNoVandalismDisturbing the peaceAny vehicle violationsVagrancyTrespassing or hunting violationMisuse of identificationIllegal possession of weaponContributing to delinquency of minorConvicted of a courts-martial or UCMJ offense*** Any YES answers must be fully explained in the Remarks section***Alcohol Usage and Abuse32. Do you drink alcoholic beverages? If you answer YES, FKHFN one choice from each column toreflect your frequency of alcohol use:1 - 3 drinks4 - 6 drinks7 - 11 drinks12 drinksDailyEvery other dayThree times weeklyWeeklyTwice monthlyMonthly33. Have you been or are you a user of alcohol habitually to excess or have you been diagnosed bya board-certified psychiatrist, other licensed physician or a licensed clinical psychologist as alcoholdependent or as suffering from alcohol abuse.34. Have you ever been formally or informally counseled concerning your drinking habits?35. Have you ever been involuntarily referred to an alcohol treatment program?36. Have you ever lost consciousness or could not recall your actions after drinking alcohol?37. Have you ever been cited, charged, accused, or prosecuted for DUI or DWI?38. Have you ever had a charge of DUI or DWI downgraded to a lesser charge?39. Have you ever been cited, detained, arrested, or charged with a crime involving alcohol?FOR OFFICIAL USE ONLY(WHEN FILLED IN)WHCA Form 89May 2021 Previous versions are obsolete3

This questionnaire when populated with data must be emailed encryptedIllegal Drugs and Drug Abuse40. Have you ever used, been accused or experimented with, even one time, an illegal drug(except as prescribed or administered by a physician licensed to dispense drugs in the practice ofmedicine, or as otherwise authorized by law) such as but not limited to:YesNoCannabis (marijuana, tetrahydrocannabinol (THC), hashish)Cocaine (crack, opium)Depressants (barbiturates, methaqualone)Hallucinogens (ecstasy, LSD, mescaline)Narcotics (heroin, morphine, opium)Cannabidiol (CBD)***Fully explain all illegal drug use to include years of use, frequency, duration, and reason for use***41.42.43.44.45.Have you ever abused or misused prescribed or over the counter medication?Have you ever taken another person’s prescribed medication?Have you ever trafficked, transferred, possessed, produced, or sold illegal drugs?Have you ever been charged with an offense involving drugs?Are you willing to take a polygraph examination?“Any changes to information after the submittal of this form will require an immediateupdate to the Personnel Security Branch ([email protected]) .Change of information includes but is not limited to financial responsibility, law orsecurity violations, foreign involvement or associations, moral conduct orUndesirable Character Traits. Failure to report can result in your immediatedisqualification from Presidential Support.”Initial for acknowledgment of the above statementFOR OFFICIAL USE ONLY(WHEN FILLED IN)WHCA Form 89May 2021 Previous versions are obsolete4

This questionnaire when populated with data must be emailed encryptedHAVE YOU ANSWERED ALL THE PREVIOUS QUESTIONS HONESTLY? (INITIAL THE CORRECT RESPONSE)YESNOREAD AND SIGN BELOW:I certify that I have read and understand the advisement statements listed on the cover page of this packet, and that theanswers on this packet are true, complete and correct to the best of my knowledge, memory and belief. I understand thatwillfully making false statements or omissions of pertinent information may result in my not receiving approval forPresidential Support Duty and further that such actions may result in punishment under the UCMJ and/or separation frommilitary service.I further understand full disclosure is required until I am removed from WHCA and that I am obligated to inform WHCASecurity of any substantial changes which occur after this security screening.***CREDIT CHECK AUTHORIZATION***: I hereby authorize the Security representatives for WHCA to obtain my creditinformation for the purpose of determining my eligibility for Presidential Support Duty. (Initial)Printed Full Name (Last, First, MI)Applicant's *****FOR INTERVIEWER USE ONLYI certify that the interview conducted on at(Date)(Location)was conducted in a fair and impartial manner. Applicant was given ample opportunity to explain any issues that weredisclosed. The interview notes and credit report are attached. (initials).Printed Name of InterviewerSignature of InterviewerThe public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time forreviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing thecollection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing the burden, to the Defense Information Systems Agency (https://www.disa.mil). Respondentsshould be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with acollection of information if it does not display a currently valid OMB control number.FOR OFFICIAL USE ONLY(WHEN FILLED IN)WHCA Form 89May 2021 Previous versions are obsolete5

This questionnaire when populated with data must be emailed encryptedREMARKS: Use this page to explain your “YES” answers.Question No. RemarksWho, What, When, Where, Why, How. Limit remarks to pertinent informationand be sure to provide a date (month and year) for when the incident occurred.Any changes to information after completing this form requires an update to the PersonnelSecurity Branch. Change of information includes but not limited to financial responsibility,law or security violations, foreign involvement or associations, moral conduct or UndesirableCharacter Traits.FOR OFFICIAL USE ONLY(WHEN FILLED IN)WHCA Form 89May 2021 Previous versions are obsolete6

Government Employment), 11652 (Classification and Declassification of National Security Information and Material) and 9397 (Federal Agency Use of Social Security Numbers). The information is used in making security determinations, granting access to classified/PSD protected i