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Centers for Medicare & Medicaid Services AFFIDAVIT OF PERSON COLLECTING FINGERPRINTS
07/2014
____________________________________________________________ Centers for Medicare & Medicaid Services require applicants to submit a fingerprint card to Accurate Biometrics for processing. This card will be used by Accurate Biometrics to submit the provider applicant’s fingerprints to the FBI to check their criminal history.
• VIEW APPLICANT IDENTIFICATION & CONFIRM FINGERPRINT CARD IS COMPLETED WITH ALL REQUIRED PERSONAL INFORMATION
• FBI REQUIRES THE USE OF THE FD-‐258 PRINT CARD FOR COLLECTING PRINTS • FINGERPRINT APPLICANT & COMPLETE INFORMATION BELOW
THIS IS A SWORN AFFIDAVIT of the person rolling fingerprints and signing the card:
I SWEAR OR AFFIRM, UNDER PENALTY OF PERJURY, that I have personally observed the applicant sign the fingerprint card. I signed the FBI card, rolled the fingerprints of the applicant and personally reviewed the completed print card information for ___________________________________ by viewing a: Applicant’s Name
Driver’s license #___________________________ State ________
Other: _______________________________________________
________________________________________________________________________ Print or Type Name of Fingerprint Tech/Law Enforcement Agent Date
Original Signature of Fingerprint Tech/Law Enforcement Agent Daytime Phone Number
Agency or Business Name Mailing Address
FD-258 (REV.12-10-07)
LEAVE BLANKAPPLICANT
TYPE OR PRINT ALL INFORMATION IN BLACK FBI LEAVE BLANKLAST NAME FIRST NAME MIDDLE NAMENAM
ALIASES AKA
DATE OF BIRTH DOBMonth Day Year
PLACE OF BIRTH POBSEX RACE HGT. WGT. EYES HAIR
LEAVE BLANK
CITIZENSHIP CTZ
YOUR NO. OCA
ORI
CLASS
REF.
FBI NO. FBI
ARMED FORCES NO. MNU
SOCIAL SECURITY NO. SOC
MISCELLANEOUS NO. MNU
SIGNATURE OF PERSON FINGERPRINTED
RESIDENCE OF PERSON FINGERPRINTED
DATE
EMPLOYER AND ADDRESS
REASON FINGERPRINTED
SIGNATURE OF OFFICIAL TAKING FINGERPRINTS
1. R. THUMB 2. R. INDEX 3. R. MIDDLE 4. R. RING 5. R. LITTLE
6. L. THUMB 7. L. INDEX 8. L. MIDDLE 9. L. RING 10. L. LITTLE
L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLYLEFT FOUR FINGERS TAKEN SIMULTANEOUSLY
* See Privacy Act Notice on Back
FD-258 (REV.12-10-07)
LEAVE BLANKAPPLICANT
TYPE OR PRINT ALL INFORMATION IN BLACK FBI LEAVE BLANKLAST NAME FIRST NAME MIDDLE NAMENAM
ALIASES AKA
DATE OF BIRTH DOBMonth Day Year
PLACE OF BIRTH POBSEX RACE HGT. WGT. EYES HAIR
LEAVE BLANK
CITIZENSHIP CTZ
YOUR NO. OCA
ORI
CLASS
REF.
FBI NO. FBI
ARMED FORCES NO. MNU
SOCIAL SECURITY NO. SOC
MISCELLANEOUS NO. MNU
SIGNATURE OF PERSON FINGERPRINTED
RESIDENCE OF PERSON FINGERPRINTED
DATE
EMPLOYER AND ADDRESS
REASON FINGERPRINTED
SIGNATURE OF OFFICIAL TAKING FINGERPRINTS
1. R. THUMB 2. R. INDEX 3. R. MIDDLE 4. R. RING 5. R. LITTLE
6. L. THUMB 7. L. INDEX 8. L. MIDDLE 9. L. RING 10. L. LITTLE
L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLYLEFT FOUR FINGERS TAKEN SIMULTANEOUSLY
* See Privacy Act Notice on Back