Form 740M Concise Note

U.S. DEPARTMENT OF ENERGY
AND
U.S. NUCLEAR REGULATORY COMMISSION

DOE/NRC FORM 740M
(4-2005)
MANDATORY DATA COLLECTION
AUTHORIZED BY 10 CFR 30, 40, 50, 70, 72, 74, 75, 150,
Public Laws 83-703, 93-438, 95-91

CONCISE NOTE
1. NAME

3. RIS

2. ATTACHMENT TO:
A. DOE/NRC 741

B. DOE/NRC 742

STREET ADDRESS

CITY

4. REPORTING PERIOD

C. DOE/NRC 742C

FROM

TO

5. TRANSACTION DATA
A.
SHIPPER'S
RIS

7A. LINE NO.

EXPIRES: 04/30/2008
APPROVED BY OMB: NO. 3150-0057
Estimated burden per response to comply with this mandatory collection request: 45 minutes. This
information is required to satisfy the provisions of the US/IAEA Safeguards Agreement. Send comments
regarding burden estimate to the Records and FOIA Privacy Services Branch (T-5 F53), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to [email protected], and to
the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0057), 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.

STATE

B.
RECEIVER'S
RIS

C.
TRANSACTION
NUMBER

D.
CORR.
NUMBER

E.
PC

F.
AC

6. REPORTING DATE

ZIP CODE

7B. ENTRY
REFERENCE

7C. TEXT OF CONCISE NOTE

To the best of my knowledge and belief, the information given above and in any attached schedules is true, complete, and correct.
8. SIGNATURE (See instructions [NUREG/BR-0006] for provisions regarding confidentiality)

9. TITLE

10. DATE

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC
BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR
REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
DOE/NRC FORM 740M (4-2005)

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