DOE F 472.3 Foreign Citizenship Acknowledgement

DOE F 472.3
10/2021

OMB Control No.
1910-1800
Expires 10/31/2021

United States Department of Energy
Foreign Citizenship Acknowledgment
The U.S. Department of Energy (DOE) has considered your foreign citizenship as it relates to eligibility for
an access authorization/security clearance under title 10, Code of Federal Regulations, Part 710, E.O.
12968 and the Government-wide Adjudicative Guidelines, as revised, approved by the President. In
accordance with these policies, exercising any right(s) associated with your foreign citizenship raises a
concern that could impact your eligibility for an access authorization/security clearance, now and in the
future.
You acknowledge that you are a citizen of the United States and ________________________ (print name
of foreign country). You further acknowledge the fact that exercising any right resulting from your foreign
citizenship, or through the foreign citizenship of a family member, unless specifically authorized in advance,
in writing, by your servicing DOE Cognizant Personnel Security Office may result in the suspension
and/or revocation of your access authorization/security clearance. This includes, but is not limited to:
1. Possession, acquisition or use of a foreign passport.
2. Military service or a willingness to bear arms for a foreign country.
3. Accepting educational, medical, retirement, social welfare, or other such benefits from a
foreign country.
4. Residence in a foreign country to meet citizenship requirements.
5. Using foreign citizenship to protect financial or business interests in another country.
6. Seeking or holding political office in a foreign country.
7. Voting in a foreign election.
8. Action to acquire or obtain recognition of a foreign citizenship.
9. Performing or attempting to perform duties, or otherwise acting, so as to serve the interests of a
foreign person, group, organization, or Government in conflict with United States national
security interests.
10. Any statement or action that shows allegiance to a country other than the United States.
___________________________________________

Printed Full Name

_______________________________________
Signature

_______________________________________
Date
OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 5 minutes per response,
including the time to exist data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. The collection of this information is mandatory to protect national
security and other critical assets entrusted to the Department. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to Office
of Environment, Health, Safety and Security, U.S. Department of Energy, 1000 Independence Avenue, S.W.,
Washington, D.C. 20585; and to the Office of Management and Budget (OMB), Paperwork Reduction Project
(1910-1800), Washington, DC 20503.