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