ML16025A033
| ML16025A033 | |
| Person / Time | |
|---|---|
| Issue date: | 12/31/2018 |
| From: | NRC/OCIO/GEMSD/IMSB |
| To: | |
| References | |
| Download: ML16025A033 (2) | |
Text
OFFICIAL USE ONLY - SECURITY-RELATED INFORMATION NRC FORM 405F U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: 3150-0047 EXPIRES: 12/31/2018 (12-2018)
Estimated burden per response to comply with this collection request: 10 minutes. This collection is a voluntary means of complying with 10 CFR Part 95 List ALL Owners, Officers, Directors, and Executive the requirements in 10 CFR 95.17. This notification is being made available to report changes to owners, officers, directors or executive Personnel (OODEP's) personnel entities holding existing Facility Clearances under 10 CFR 95 or MD 12.2. Send comments regarding burden estimate to the Information Services Branch (O-1 F21), U. S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.
Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0047), Office of NOTE: Consistent with Executive Order 12829 and the requirements in 10 CFR 95.18, individuals identified as Key Management Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid Personnel (KMP) are required to disclose their Social Security numbers in order to obtain a personnel security clearance. OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
Company's Current Legal Name, Address, and Other names used (e.g., doing business as): Date Submitted:
Phone Number of Company's Principal Executive Offices:
Tax Identification No.
Date Company was Incorporated:
State of Incorporation: Choose an item or type in (Must provide any name or address change of the Company's principal executive office and date(s) of change during the past 10 years on the Attachment page).
Organization Status: Stock Ownership:
Corporation Sole Proprietorship Partnership Privately-Owned Subsidiary of:
Other General Limited Publicly-Traded CLEARANCE HELD AND/OR NAME IF OWNER, POSITION TITLES SSN BEING OBTAINED AND CITIZENSHIP (First Name, Initial, Last Name) % OF OWNERSHIP ISSUING AGENCY Facility Security Officer 1
The above information, i.e., name, titles, etc., must be provided for the following: (a) the proprietor of a sole proprietorship; (b) all individuals managing the business affairs of a corporation. In most cases, these individuals are identified in the Articles of Incorporation or By-Laws and include the Board of Directors, President, Secretary, and Treasurer; (c) the General Partner(s) of a Limited Partnership; and (d) all partners of a General Partnership. 2 In addition, privately-held entities must provide the above information, i.e., name, titles, etc., for all owners, and also provide the percentage of issued stock/shares held by each owner.
List certified correct by: (Typed or Printed Name and Title) SIGNATURE DATE NRC FORM 405F (12-2018)
NRC FORM 405F U. S. NUCLEAR REGULATORY COMMISSION (12-2018) 10 CFR Part 95 List ALL Owners, Officers, Directors, and Executive Personnel (OODEP's)
INSTRUCTIONS:
Provide requested OODEP information in accordance with the following instructions. In addition, the OODEP listing must be certified as being accurate, current, and complete by an authorized official of the organization [i.e., a person authorized to represent and sign for the organization as officially recorded by the organization (that is, in the document which sets forth the terms and conditions for its operation and management--the bylaws, operating agreement, partnership agreement, etc.)] or any other employee, identified by name, of the organization, if designated in writing by such an authorized official as having been delegated authority to execute the FOCI repre. & certt. On behalf of the organization:
Owners. The requested information on owners and representatives or agents of stockholders is to be attached to the organization's OODEP listing:
- 1. For privately-owned organizations:
- a. Provide the following information for each person (i.e., human being) who directly or indirectly owns or has beneficial ownership of 5 percent or more of any class of the organization's securities or who has directly or indirectly subscribed 5 percent or more of the organization's total capital commitment:
(1) If the beneficial owner holds a position as an OODEP in the organization and is identified on the OODEP listing, provide the individual's name with the class and number of shares of capital stock he/
she owns of the organization's securities or the capital commitment he/she has subscribed.
(2) If the beneficial owner does not hold a position as an OODEP in the organization and is not identified on the OODEP listing, provide the individual's name, address, and the class and number of shares of capital stock he/she owns of the organization's securities or the capital commitment he/she has subscribed. If known, information on the individual's citizenship should also be provided.
- b. Provide the following information for each legal entity which directly or indirectly owns or has beneficial ownership of 5 percent or more of any class of the organization's securities or which has directly or indirectly subscribed 5 percent or more of the organization's total capital commitment:
The legal name (i.e., as specified in charter) with the address of its principal executive offices and the class and number of shares of capital stock the entity owns of the organization's securities or the capital commitment the entity has subscribed. In addition, if the entity is controlled by another organization, the country of ultimate legal residence must be provided.
- c. Provide the name of any representative(s) or agent(s) of any owner (person or entity), if any, who hold positions, such as Board member (or similar type of governing body), officers, executive personnel, or general partners in your organization. Also identify the owner which the individual is representing.
- 2. For publicly-traded organizations:
- a. Provide the most recent copies of any Schedules 13D and/or 13G received from any beneficial owners (foreign or domestic) who hold 5 percent or more of the organization's securities.
- b. Provide the name of any representative(s) or agent(s) of any stockholder (person or entity), if any, who hold positions, such as Board member (or similar type of governing body), officers, executive personnel, or general partners in your organization. Also identity the stockholder which the individual is representing.
Officers: Identify and provide requested information (i.e., names, titles, etc.) for all of the organization's officers on the OODEP listing.
The definition of officers is: Those persons in positions established as officers as officially recorded by the organization (that is, in the document filed for the organization's existence and the document which sets forth the terms and conditions for its operation and management--the articles of incorporation and bylaws; articles of organization and operating agreement; certificate of limited or general partnership and the partnership agreement; etc.). However, excluded from this definition are: (a) assistant vice presidents who have no management responsibilities related to performance on classified contracts; (ii) assistant secretaries; and (iii) assistant treasurers.
Directors: Identify and provide requested information (i.e., names, titles, etc.) for all of the organization's directors on the OODEP listing, to include identification of the Chairman of the Board and any Vice Chairman. If the organization has no Chairman of the Board of Directors, identify the individual who performs those functions at board meetings.
The definition of directors is: Members of the board or similar governing body chosen to direct the affairs of a corporation or institution.
Executive Personnel: Identify and provide requested information (i.e., names, titles, etc.) for all of the organization's executive personnel on the OODEP listing.
The definition of executive personnel is: Those individuals who perform policy making functions for the organization, or any other person in charge of a principal business unit, division, or function.
Facility Security Officer: Identify and provide requested information (i.e., name, title, etc.) for the organization's Facility Security Officer.
The definition of a Facility Security Officer is: The individual at the facility assigned the responsibility of administering the requirements of the Safeguards and Security Program within the facility.
Spouse of a sole proprietor: For those sole proprietorships operating in community property states, identify and provide requested information (i.e., all information required on the OODEP listing) on a sole proprietor's spouse, if any. If there is no spouse, so state.
Vacant positions: If any OODEP position is vacant, so state and include estimated date vacancy will be filled.
Mail Completed NRC Form 405F to the following address: USNRC Office of Nuclear Security and Incident Response Mail Stop: O2 D15 NOTE: Consistent with Executive Order 12829 and the requirements in 10 CFR 95.18, 11555 Rockville Pike individuals identified as Key Management Personnel (KMP) are required to disclose their Rockville, MD 20852-2738 Social Security numbers in order to obtain a personnel security clearance.