Form NRC Form 136 NRC Form 136 Security Termination Statement

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(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 U.S. Nuclear Regulatory Commission
(NRC) on NRC Form 136. This information is maintained in a system of records designated as NRC-39 and
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 located in the 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, as 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 Parts
10, 11, 25, 73; Pub. L. 99-399 (100 Stat. 876); OMB Circular No. A-130, Revised; 5 CFR Parts 731 and 732
and authorities cited therein; Pub. L. 99-500 (100 Stat. 1783-335).
2. PRINCIPAL PURPOSE(S): An individual's signature on this form initiates action to terminate his/her access
authorization and indicates an individual's acknowledgment/acceptance of continuing responsibilities following
the termination of their access authorization and/or employment for the protection of classified and sensitive
unclassified information that individual had access to in the course of performing official duties.
3. ROUTINE USE(S): Information may be used on a need-to-know basis by NRC officials, Hearing Examiners,
Personnel Security Review Panel members, OPM, CIA and other Federal agencies to determine/certify
clearance or access authorization; to determine eligibility for access to NRC buildings or access to Federal
automated information systems or data; to maintain the NRC personnel security program; and to provide
licensees criminal history information needed for their unescorted access or access to safeguards 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: It is voluntary that you furnish the requested information. However, non-receipt
of this signed form may result in a failure to terminate an individual's access authorization.
5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Facilities and Security, Office of
Administration, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

NRC FORM 136

U.S. NUCLEAR REGULATORY COMMISSION

(M-YYYY)
NRC MD 12.3

SECURITY TERMINATION STATEMENT

APPROVED BY OMB: NO. 3150-XXXX

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory information collection request:
6 minutes. This submittal is used by NRC to initiate termination of access authorization. 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-XXXX), 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.

NAME (Print full name, include all other names used)

EMPLOYER

NRC ACCESS AUTHORIZATION FILE NUMBER

EFFECTIVE DATE OF TERMINATION

I make the following statement in connection with the termination of my access authorization
granted by, or pending with, the U.S. Nuclear Regulatory Commission (NRC):
1. I shall not unlawfully reveal to any person any National Security Information, Restricted
Data, or other classified information, or unclassified Safeguards Information of which I may
have gained knowledge except as authorized by law, regulations of the NRC, or in writing
by officials of the NRC empowered to grant permission for such disclosure.
2. I am aware that the Atomic Energy Act of 1954, as amended, and U.S. Code, Title 18,
"Crimes and Criminal Procedures," prescribe penalties for unauthorized disclosure of
Restricted Data, Formerly Restricted Data, Safeguards Information, and other information
relating to the national defense.
3. I am aware that, unless and until I am released in writing by an authorized representative of
the U.S. Government, all conditions and obligations imposed upon me by virtue of my
having executed SF 189, "Classified Information Nondisclosure Agreement," or SF 312 of
the same title, remain in full force and effect.
4. I am aware that I may be liable for damages if I reveal to any unauthorized person sensitive
unclassified information (e.g., privacy information, proprietary Information) of which I have
gained knowledge as a result of my employment, affiliation with NRC.
5. I have destroyed, in accordance with NRC security regulations or transferred to persons
designated by the NRC, all classified and/or sensitive unclassified information which I may
have had in my possession.
6. I am aware that I may be subject to criminal penalties if I have made any statement of
material facts knowing that such statement is false or if I willfully conceal any material fact
(Title 18, U.S. Code, Section 1001).
SIGNATURE -- PERSON CONDUCTING BRIEFING

SIGNATURE -- PERSON EXECUTING THIS FORM

EMPLOYER OF PERSON CONDUCTING BRIEFING AND TITLE OF POSITION HELD

DATE AND PLACE WHERE SIGNED

NRC FORM 136 (M-YYYY)