DOE-F-5631.34 US Department of Energy Data Report on Spouse/Cohabitant

DOE F 5631.34
(xx/xx)
All Other Editions Are Obsolete

OMB Control No.
1910-1800
OMB Disclosure
Statement on Reverse

U. S. DEPARTMENT OF ENERGY

DATA REPORT ON SPOUSE/COHABITANT

This information is required to assess your DOE access authorization (security clearance) eligibility.
PLEASE READ THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING THIS REPORT.

1. Name of Employee or Applicant (Last, First, Middle):

2. Current Name of
(Last, First, Middle):

Spouse

Cohabitant (check one)

3. Other Names Used by Employee or Applicant (Maiden Name
and/or names previously used):

4. Other Names Used by Spouse/Cohabitant (Maiden name/
and/or name(s) previously used – include timeframe(s)):

5. Social Security Number of Employee or Applicant:

6. Social Security Number of Spouse/Cohabitant:

7. Beginning Date of Marriage/Cohabitation:

8. Date of Birth of Spouse/Cohabitant:

9. Current Physical Address of Spouse/Cohabitant:

10. Place of Birth of Spouse/Cohabitant (City, State, Country):

11. Citizenship of Spouse/Cohabitant (complete a. or b. – whichever applies):
a.

U.S.

b.

Foreign National

By birth

Alien Registration Number/Date/City, State Issued:

Derivative (provide Certificate Number):

Foreign country(ies) where spouse/cohabitant holds
citizenship:

Naturalization (provide Certificate
Number/Date/City, State issued):

12. If your Spouse/Cohabitant is a U.S. Citizen, does he/she hold dual citizenship with any country(ies)?:
No

Yes – list the country(ies):

DOE File No. (To be filled in by Cognizant Personnel Security
Office):

Signature of Employee

Date Signed

OFFICIAL USE ONLY
(WHEN FILLED IN)

DOE F 5631.34
(xx/xx)
All Other Editions Are Obsolete

OMB Control No.
1910-1800

General Information
Who Should Submit
This form will be completed by persons who marry or begin cohabitating after the time they submit SF 86, “Questionnaire for National
Security Positions,” in connection with U.S. Department of Energy (DOE) access authorization (security clearance). DOE Form 5631.34
must be submitted within 45 calendar days of the marriage/cohabitation. For the purposes of this form a cohabitant defined as a
person who lives with you in a spouse-like relationship or with a similar bond of affection or obligation, but is not your legal spouse, child,
or other relative (in-laws, mother, father, brother, sister, etc.).
General Instructions
Complete this form in its entirety. Type or print all answers. Enter “none” when applicable. If more space is needed, use the space
below. Specific questions may be referred to the local DOE Cognizant Personnel Security Office that is processing or has processed the
request for your DOE access authorization (security clearance).
18 U.S.C. SECTION 1001; ACT OF JUNE 25, 1948; 62 STAT. 749; MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE
STATEMENT OR PRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTERS WITHIN ITS
JURISDICTION.
Privacy Act Information Statement
Collection of the information requested is authorized by the Atomic Energy Act of 1954, as amended, Section 145b, Executive Orders
10450, 10865, or 12968, and DOE O 472.2, “Personnel Security.” The information placed on this form will be used in determining an
individual’s eligibility for a DOE access authorization (security clearance). Disclosure of the information requested on this form is
voluntary; however, if the information is not provided, the request for DOE access authorization (security clearance) will not be
processed or any DOE access authorization (security clearance) then in effect may be terminated in accordance with 10 CFR 710. The
original and/or copies of this form are maintained in the DOE Personnel Security File (PSF) of the individual processed for DOE access
authorization (security clearance). Access to the DOE PSFs is permitted as stipulated in DOE O 472.2 and as listed in Routine Uses in
the DOE System of Records, DOE-43, “Personnel Security Files.”
OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Health, Safety and Security’s Office of Departmental Personnel
Security (HS-53), U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington, D.C. 20585-1290; and to the Office of
Management and Budget (OMB), Paperwork Reduction Project (1910-1800), Washington, D.C. 20503.