Form NRC Form 354 NRC Form 354 Data Report On Spouse

GENERAL INFORMATION
Who should submit
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 authoriziation, 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.
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
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 71 Federal
Register 59642 (October 10, 2006), or the most recent Federal Register publication of the NRC's "Republication of
Systems of Records Notices" that is available at the NRC Public Document Room, 11555 Rockville Pike, Rockville,
Maryland or located in NRC's Agencywide Documents Access and Management System (ADAMS).
1.

AUTHORITY: 40 U.S.C. 318; 42 U.S.C. 2165 and 2201(i); Executive Order (E.O.) 9397; E.O. 10450, as
amended by E.O.s 10491, 10531, 10548, 10550, 11605, 11785, 12107; E.O. 12958, amended by E.O. 13292;
E.O. 12968; E.O. 10865, as amended by E.O.s 10909, 11382, modified by E.O. 12038; 10 CFR 10, 11, 25, and
73; Pub. L. 99-399 (100 Stat. 876); OMB Circular No. A-130, Revised; 5 CFR 731 and 732 and authorities cited
therein; Pub. L. 99-500 (100 Stat. 1783-335).

2.

PRINCIPAL PURPOSE(S). To perform an initial security check on an alien spouse to assure the respondent is
not a security risk to determine an employee or applicants 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, or to
NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis.

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.

NRC FORM 354

U.S. NUCLEAR REGULATORY COMMISSION

(M-YYYY)

DATA REPORT ON SPOUSE

EXPIRES: MM/DD/YYYY
APPROVED BY OMB: NO. 3150-0026
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 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, (3150-0026), 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 (SF 86,
"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)

6. PRESENT NAME OF SPOUSE/COHABITANT (Last, First, Middle)

2. OTHER NAMES USED BY EMPLOYEE OR APPLICANT
(Maiden name and/or other names previously used)

7. OTHER NAMES USED BY SPOUSE/COHABITANT
(Maiden name and/or all other names previously used)

3. SOCIAL SECURITY NUMBER (Employee or Applicant - Last 4 Digits)

8. DATE AND PLACE OF BIRTH OF SPOUSE/COHABITANT
PLACE

DATE

4. EMPLOYMENT (Name, Address and Zip Code)(Present Assignment)

9. PRESENT ADDRESS OF SPOUSE/COHABITANT

5. DATE AND PLACE OF MARRIAGE
DATE

PLACE

10. CITIZENSHIP OF SPOUSE/COHABITANT (Complete a. or b., whichever applies)
a. U.S.

b. ALIEN
ALIEN REGISTRATION NUMBER

BY BIRTH
DERIVATIVE (Provide certificate number)

DATE OF ENTRY

PORT OF ENTRY

BY NATURALIZATION (Provide certificate number)
DATE

PLACE

PRESENT CITIZENSHIP

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 PARENTS -- (living or dead)
A. RELATION

B. NAME IN FULL

13. SIGNATURE OF EMPLOYEE OR APPLICANT

NRC FORM 354 (M-YYYY)

C. DATE OF
BIRTH

D. ADDRESS

E. COUNTRY
OF BIRTH

F. PRESENT
CITIZENSHIP

14. DATE

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