Form DOE/NRC Form 740M DOE/NRC Form 740M Concise Note

DOE/NRC FORM 740M

U. S. DEPARTMENT OF ENERGY
AND
U. S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)
MANDATORY DATA COLLECTION
AUTHORIZED BY 10 CFR 30, 40,
50, 70, 72, 74, 75, 150
Public Laws 83-703, 93-438, 95-91

CONCISE NOTE

1. Name

EXPIRES: (MM/DD/YYYY)

4. Reporting Period (MM/DD/YYYY)
From Date
To Date

3. RIS

2. Attachment To:
A. DOE/NRC 741

B. DOE/NRC 742

C. DOE/NRC 742C

5. Transaction Data

Street Address
A.
Shipper's RIS
City

7A. Line No.

APPROVED BY OMB: NO. 3150-0057

Estimated burden per response to comply with this mandatory collection request: 45 minutes. This information is required to satisfy the provisions of the US/
IAEA Safeguards Agreement. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by email to [email protected], and the OMB reviewer at: OMB Office of Information and
Regulatory Affairs, (3150-0057), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email:
[email protected]. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
document requesting or requiring the collection displays a currently valid OMB control number.

State

B.
Receiver's RIS

C.
Transaction Num.

D.
Correction Num.

E. PC

F. AC

6. Reporting Date

Zip Code

7B. Entry
Reference

7C. Text of Concise Note

To the best of my knowledge and belief, the information given above and in any attached schedules is true, complete, and correct.
8. Signature (See instructions [NUREG/BR-0006] for provisions regarding confidentiality).

9. Title

10. Date

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS.
18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.

DOE/NRC FORM 740M (MM-DD-YYYY)