ML13083A094

NRC Form 354 - Data Report on Spouse

ML13083A094
Person / Time
Issue date:	06/30/2018
From:	NRC/OCIO/GEMSD/IMSB
To:
References
Download: ML13083A094 (2)

Text

APPROVED BY OMB: NO. 3150-0026 DATA REPORT ON SPOUSE NRC FORM 354 (06-2018)U.S. NUCLEAR REGULATORY COMMISSION EXPIRES: 05/31/2021 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 Information Services Branch (T-2 F43), 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, (3150-0026), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

INSTRUCTIONS: This form shall be completed by any applicant who: (a) marries after completing the personnel security form (SF86, "Questionnaire for National Security Positions"); (b) marries after having been granted an access authorization, employment clearance; or (c) whose spouse is an alien. 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)

Date (MM/DD/YYYY)

Place of Marriage

6. Present Name of Spouse/Cohabitant (Last, First, Middle)

7. Other Names Used by Spouse/Cohabitant

(Maiden name and/or other names previously used)

8. Date and Place of Birth of Spouse/Cohabitant 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.By Birth Derivative (Provide certificate number)

By Naturalization (Provide certificate number)

Date of Naturalization Place of Naturalization Certificate Number

b. Alien Alien Registration Number Date of Entry Port of Entry Present Citizenship

11. Does your Spouse/Cohabitant hold dual Citizenship with any Country(ies)?

Yes (List the coutry(ies))

No List country(ies) where spouse or cohabitant holds citizenship:

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

A. Relation B. Name in Full C. Date of Birth D. Address E. Country of Birth F. Present Citizenship Father Mother 13. Signature of Employee or Applicant

14. Date 15. Signature of Spouse or Cohabitant

16. Date NRC FORM 354 (06-2018)

GENERAL INFORMATION Who should submit 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.

General Instructions This form will be completed by persons who marry or cohabitate after the time they submit SF-86, "Questionnaire for

National Security Positions," or marries or cohabitates after having been granted an access authorization, or employment

clearance in connection with 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. 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.

PRIVACY ACT STATEMENT NRC FORM 354 DATA REPORT ON SPOUSE

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.

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, described at 81 Federal Register 81348 (November 17, 2016), 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.

13256; E.O. 13587; 10CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130, Revised; 5 CFR 731, 732, and

authorities cited therein.