Form 354 Data Report On Spouse

NRC FORM 354

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

DATA REPORT ON SPOUSE

APPROVED BY OMB: NO. 3150-0026

EXPIRES: (MM/DD/YYYY)

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 FOIA, Privacy, and Information Collections Branch (T-5 F53), U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001, or by 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 (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)

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

5. Date and Place of Marriage (Employee or Applicant)
Date (MM/DD/YYYY)

Place of Marriage

7. Other Names Used by Spouse/Cohabitant
(Maiden name and/or other names previously used)

8. Date and Place of Birth of Spouse/Cohabitant
Place of Birth

Date of Birth

9. Present Address of Spouse/Cohabitant

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
By Naturalization (Provide certificate number)
Place of Naturalization

Date of Naturalization

Port of Entry

Present Citizenship

Certificate Number

No

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

Yes (List the coutry(ies))

List country(ies) where spouse or cohabitant holds citizenship:

12. Spouse's Parent -- (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 (MM-YYYY)

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 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 spouselike 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
NRC FORM 354
DATA REPORT ON SPOUSE

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; 10 CFR Parts 10, 11, 14, 25, 50, 73, 95; OMB Circular No. A-130, Revised; 5 CFR 731, 732, and
authorities cited therein.
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.