Fingerprint Card Instructions PA Rev 061113 (2)

1 Centers for Medicare & Medicaid Services AFFIDAVIT OF PERSON COLLECTING fingerprints _____ 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 07/2014 LEAVE BLANK TYPE OR PRINT ALL INFORMATION IN BLACK FBI LEAVE BLANK.

2 NAM. APPLICANT. * See Privacy Act Notice on Back LAST NAME FIRST NAME MIDDLE NAME. FD-258 ( ). SIGNATURE OF PERSON FINGERPRINTED ALIASES AKA O. R. I. RESIDENCE OF PERSON FINGERPRINTED DATE OF BIRTH DOB. Month Day Year CITIZENSHIP CTZ SEX RACE HGT. WGT. EYES HAIR PLACE OF BIRTH POB. DATE SIGNATURE OF OFFICIAL TAKING fingerprints . YOUR NO. OCA. CMS LEAVE BLANK. EMPLOYER AND ADDRESS. FBI NO. FBI. CLASS. ARMED FORCES NO. MNU. REASON FINGERPRINTED SOCIAL SECURITY NO. SOC. REF. Centers for Medicare and Medicaid Services MISCELLANEOUS NO. MNU. 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. LEFT FOUR FINGERS TAKEN SIMULTANEOUSLY L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY. LEAVE BLANK TYPE OR PRINT ALL INFORMATION IN BLACK FBI LEAVE BLANK. NAM. APPLICANT. * See Privacy Act Notice on Back LAST NAME FIRST NAME MIDDLE NAME. FD-258 ( ). SIGNATURE OF PERSON FINGERPRINTED ALIASES AKA O.

3 R. I. RESIDENCE OF PERSON FINGERPRINTED DATE OF BIRTH DOB. Month Day Year CITIZENSHIP CTZ SEX RACE HGT. WGT. EYES HAIR PLACE OF BIRTH POB. DATE SIGNATURE OF OFFICIAL TAKING fingerprints . OCA. CMS. YOUR NO. LEAVE BLANK. EMPLOYER AND ADDRESS. FBI NO. FBI. CLASS. ARMED FORCES NO. MNU. REASON FINGERPRINTED SOCIAL SECURITY NO. SOC. REF. Centers for Medicare and Medicaid Services MISCELLANEOUS NO. MNU. 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. LEFT FOUR FINGERS TAKEN SIMULTANEOUSLY L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY. This page for information only -- FBI Privacy Statement