SPHS

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001297553
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Release Date: February 19, 2008
• Case Number: F-2005-00558
• Publication Date: July 22, 1976

 (b) (3) (b) (6) SUPPLEMENTAL PERSONAL HISTORY STATEMENT SECTION I.                                              INSTRUCTIONS Answer all  questions completely.  If question does  not  apply,  write  "NA."  Write  "UNKNOWN"  only if you do not  know the answer and  it  cannot  be     obtained  from personal  records.  If additional  space  is  required  use  extra pages,  same  size as  this and sign each page. Reference continued  item by related section and  item number. 1 . FULL  NAME  (last-first-middle) 2.DATE  OF B I R T H 3 .  PLACE  OF BIRTH (City, State, Country)   4.  SOC.  SEC. NO. Mills       Montrell E.                 1 31 Jan. 192 Paducah-T xas                              Cottle 5.  PRESENT STATUS  (Single,       married,  divorced, annulled, remarried, widowed)  SPECIFY: Ma 6.  STATE  DATE, PLACE.  AND REASON  FOR ALL DIVORCES OR  ANNULMENTS NA 7.  LIST  EDUCATION SINCE  DATE  OF LAST  PHS: NA 8.  LIST  ANY  PART  TIME EMPLOYMENT  SINCE  DATE  OF  LAST  PHS: NA SECTION It.                                                        SPOUSE 1.  NAMEOF     SPOUSE (last-first-middle-maiden) 2.  DATE  OF  BIRTH 3.  PLACE  OF  BIRTH  (spouse) Mills          Marjorie E. 22 June 1923 Lansing     Michigan 4.  DATE  AND  PLACE OF  MARRIAGE 5.  CITIZENSHIP  OF  SPOUSE        (If naturalized,   indicate  date  &  place 13 January 1945 Pampa Texas; of naturalization & certificate no.) US 6.  OCCUPATION 7.  PRESENT      EMPLOYER  AND BUSINESS ADDRESS OF  SPOUSE Housewife Hone address SECTION III.        CHILDREN AND OTHER DEPENDENTS (Provide information for all children and dependents) NAME RELATIONSHIP DATE &  PLACE  OF  BIRTH CITIZENSHIP ADDRESS 3 sons. None dependent at his time. MARRIAGE OR ADOPTION WHO EITHER (1) LIVE ABROAD, RELATIVES BY BLOOD , SECTION IV. (2) ARE NOT U.S. CITIZENS OR (3) WORK FOR A FOREIGN GOVERNMENT NAME      (Last-First-Middle) 1 2. RELATIONSHIP 3.DATE  OF  BIRTH 4.  PLACE OF  BIRTH (City,  State, . Country) NA 5.  CITIZENSHIP (Country) 6.  ADDRESS  OR COUNTRY  IN WHICH'RELATIVE RESIDES (1) 7.  EMPLOYED  BY 8.  FREQUENCY  OF  CONTACT 9.     DATE  OF  LAST  CONTACT NAME  (Last-First-Middle) 1 2. RELATIONSHIP 3.DATE  OF  BIRTH 4.  PLACE OF  BIRTH  (City,  State, . Country) 5. CITIZENSHIP (Country) 6.  ADDRESS OR COUNTRY   IN WHICH RELATIVE RESIDES (2) 7.  EMPLOYED  BY 8.  FREQUENCY  OF  CONTACT 9.     DATE  OF  LAST  CONTACT SECTION V.                            PERSONS TO BE NOTIFIED IN CASE OF EMERGENCY 1.  NAME  (Last-First-Middle) 2.  RELATIONSHIP Mills, Marjorie E. Wife 3.  HOME ADDRESS (Number,  Street,  City,  State,  ZIP Code) 4.  HOMETELEPHONE  NUMBER 2626 Sigmona St.Falls Church, Virginia ,2206 560 0036 5.  BUSINESS ADDRESS, (Number,  Street,  City,.State, ZIP Code)- I&  LC.ATS J1AM   OF FIRM 6.  BUSINESS TELEPHONE  NUMBER &  EXT. OR  EMPLOYER. IF APPLICABLE                                             A PROO`b ll DATE:  NOV 2007 NA 7.  IN CASE OF  EMERGENCY,  OTHER CLOSE RELATIVES  (spouse,  mother,  father     ...)  MAY ALSO BE  NOTIFIED.  IF SUCH NOTIFICATION' IS NOT DESIRABLE BECAUSE       OF HEALTH OR OTHER REASONS.   PLEASE       IDENTIFY THE PERSONS  NOT TO BE  NOTIFIED AND THE REASON. NA FORM  444e OBSOLETE  PREVIOUS                                                                                                                                                                         (4) 10.74           EDITIONS SECTION VI.     RESIDENCE (Since date of last PHS,  if overseas residence indicate only city and country) ADDRESS  -  LAST RESIDENCE FIRST (NUMBER,  STREET,  CITY,  STATE,  COUNTRY) IF APARTMENT  INCLUDE  APARTMENT NUMBER(S). INCLUSIVE  DATES (MO.  & YEAR) 2627 West Newton Circle, Irving,Texas USA FROM- 1953 TO- 1965 2626 Sigmona St. ]Falls Church,Va. USA 1965 date SECTION VII.          REFERENCES - LIST THREE (3) SOCIAL REFERENCES RESIDING IN THE UNITED STATES ONE OF WHOM SHOULD NOT BE AN AGENCY"EMPLOYEE,.'DO NOT INCLUDE RELATIVES. NAME RESIDENTIAL  ADDRESS Pus Nrqq SS Dwain Hendrix Recently moved--still lives in Irvin   Texas Dal as                                                                             ex SUPERVISORS - LIST YOUR CURRENT AND TWO PRLVIQU15 SUPERVISORS NAME BUSINESS  ADDRESS TELEPHONE  NO. YEARS/KNOWN FROM-          TO- 1973                                                                                                                                               date 1968 date nulm 1965 date AL DECLARATIONS I.  HAVE minor YOU  BEEN  ARRESTED,   INDICTED,. OR  CONVICTED  FOR ANY  VIOLATION  OF  LAW  (Other than  for traffic       violations)  SINCE  THE  DATE  OF  YOUR  LAST  PHS7 YES  (explain below) X NO 2.  SINCE WHICH THE  DATE  OF  YOUR  LAST  PHS,  HAVE THERE   BEEN ANY  UNFAVORABLE  INCIDENTS  IN YOUR   LIFE MIGHT REQUIRE  EXPLANATION? YES  (explain below)  _ X NO 3.  HAVE PHS? YOU  USED  ANY ILLEGAL,  PROHIBITED  DRUGS    OR  NARCOTICS  SINCE  THE  DATE OF YOUR  LAST YES  (explain below) X X NO 4.  HAVE NOT  P YOU  HAD  ANY NON-OFFICIAL  CONTACT  WITH  REPRESENTATIVES  OF  A     FOREIGN  GOVERNMENT. REVIOUSLY  REPORTED? YES  (explain below) X NO SECTION X.                                                 ADDITIONAL REMARKS DATE 22 SIGNATURE  OF  EMPLOYEE duly 1976