ML21025A411

NRC 354 (OMB Copy) (01-20-2021) Lf

ML21025A411
Person / Time
Issue date:	01/27/2021
From:	Emily Robbins NRC/ADM/DFS/PSB
To:
Robbins E
Shared Package
ML21013A033	List: ML21013A035 ML21025A411
References
Download: ML21025A411 (2)

Text

NRC FORM 354 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0026 EXPIRES: (MM/DD/YYYY)

(MM-YYYY) Estimated burden per response to comply with this mandatory collection request: 12 minutes. The information collection is needed by NRC to perform an initial security check on an alien spouse to assure the respondent is not a security risk. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC DATA REPORT ON SPOUSE 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov,and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0026), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail:

oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

INSTRUCTIONS: This form will be completed by persons who marry or cohabitate after the time they submit the Standard Form 86 (SF-86), "Questionnaire for National Security Positions," or marries or cohabitates after having been granted an access authorization, or employment clearance in connection with the U.S. Nuclear Regulatory Commission (NRC) access authorization (security clearance).This form will be submitted to the Federal Bureau of Investigations for the purpose of conducting name checks on the spouse/cohabitant and spouse's parents.

1. Name of Employee or Applicant (Last, First, Middle) 2. Other Names Used By Employee or Applicant (Maiden name and/or other names previously used)

3. Social Security Number (Last 4 Digits) 4. Employment (Name, Address and Zip Code)(Present Assignment)

5. Date and Place of Marriage (Employee or Applicant) 6. Present Name of Spouse/Cohabitant (Last, First, Middle)

Date (MM/DD/YYYY) Place of Marriage

7. Other Names Used by Spouse/Cohabitant 8. Date and Place of Birth of Spouse/Cohabitant (Maiden name and/or other names previously used)

Date of Birth Place of Birth

9. Present Address of Spouse/Cohabitant

10. Citizenship of Spouse/Cohabitant (Complete a. or b., whichever applies)

a. U.S. b. Alien By Birth Alien Registration Number Derivative (Provide certificate number)

Date of Entry Port of Entry By Naturalization (Provide certificate number)

Present Citizenship Date of Naturalization Place of Naturalization Certificate Number

11. Does your Spouse/Cohabitant hold dual Citizenship with any Country(ies)? No Yes (List the country(ies))

List country(ies) where spouse or cohabitant holds citizenship:

12. Spouse's Parent -- (Living or dead)

E. Country of F. Present A. Relation B. Name in Full C. Date of Birth D. Address Birth Citizenship Father Mother

13. Signature of Employee or Applicant 14. Date

15. Signature of Spouse or Cohabitant 16. Date NRC FORM 354 (MM-YYYY)

GENERAL INFORMATION Who should submit This form will be completed by persons who marry or cohabitate after the time they submit the Standard Form 86 (SF-86),

"Questionnaire for National Security Positions," or marries or cohabitates after having been granted an access authorization, or employment clearance in connection with the U.S. Nuclear Regulatory Commission (NRC) access authorization (security clearance). The form must be submitted within 45 days of the marriage/cohabitation if the spouse/

cohabitant has never held a NRC access authorization (security clearance). For the purposes of this form, a cohabitant is defined as an individual with whom you live, other than a legal spouse, child, or other relative (in-laws, mother, father, brother, sister, etc.), with whom you have a spouse- like relationship or similar bond of affection.

General Instructions Complete this form in its entirety. Type or print all answers. Enter "none" when applicable. If more space is needed, attach an additional sheet. Specific questions may be referred to the NRC Personnel Security Office.

PRIVACY ACT STATEMENT NRC FORM 354 DATA REPORT ON SPOUSE Pursuant to 5 U.S.C. 552(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the Nuclear Regulatory Commission (NRC) on NRC Form 354. This information is maintained in a system of records designated as NRC-39 and described at 84 Federal Register 71568 (December 27, 2019), or the most recent Federal Register publication of the NRC's "Republication of Systems of Records Notices" located in NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY: 42 U.S.C. 2011 et seq,; 42 U.S.C. 2165, 2201(i); 2201a, and 2284; 42 U.S.C. 5801 et seq.; Executive Order (E.O.) 9397; as amended by E.O. 13478; E.O. 10450, as amended; E.O. 10865, as amended; E.O. 13467; E.O.

13526; E.O. 13587; 10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130, Revised; 5 CFR parts 731, 732, and authorities cited therein.

2. PRINCIPAL PURPOSE(S): To perform an initial security check on a spouse/cohabitant to assure the respondent is not a security risk for determining an employee or applicant's initial or continuing eligibility for NRC employment or access authorization.

3. ROUTINE USE(S): Information in these records may be used by the Division of Facilities and Security and on a need-to-know basis by appropriate NRC officials, Hearing Examiners, Personnel Security Review Panel members, Office of Personnel Management, Central Intelligence Agency, and other Federal agencies to determine clearance or access authorization eligibility; to determine eligibility for access to NRC buildings or access to Federal automated information systems or data; to certify clearance or access authorization; to maintain the NRC personnel security program; to provide licensees information needed for unescorted access or access to safeguard information determinations. Information may be disclosed in accordance with any of the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate Federal, State, local or Foreign agency in the event the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding. In addition, this information may be transferred to an appropriate Federal, State, local and foreign agency to the extent relevant and necessary for an NRC decision about you or to the extent relevant and necessary for that agency's decision about you. Information may also be disclosed, in the course of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; or to appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: Disclosing this information is voluntary; however, if it is not supplied, your clearance processing may be delayed, or your application may not be processed.

5. SYSTEM MANAGER AND ADDRESS: Director, Division of Facilities and Security, Office of Administration, U.S.

Nuclear Regulatory Commission, Washington, DC 20555-0001.