Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
March 20, 2008
Sequence Number: 
Case Number: 
Publication Date: 
May 31, 1961
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Complete in duplicate. The data recorded on this form, is essential in determining travel expenses allowable in connection with leave at government expense, overseas duty, return to residence upon separation, and for providing current residence and dependency infor- ' s official personnel folder, mation required in the event ofan employee emergency. The original of this' form will be filed in the employee NAME OF EMPLOYEE ast) (First) (Middle) ( SOCIAL SECURITY NUMBER RESIDENCE DATA ,UCE WHEN INITIALLY APPOINTED PLACE OF RESIDE r LAST PLACE OF RESIDENCE IN CONTINENTAL U.S. (If appointed abroad) rJ j1 PLACE IN CONTINENTAL U.S. DESIGNA ED AS PERMANENj REST- HOME LEAVE RESIDENCE 2. MARITAL STATUS (Check one) SINGLE MARRIED SEPARATED DIVORCED WIDOWED ANNULLED AAGE I IF MARRIED, PLACE OF ARR DATE OF MARRIAGE . I IF DI ORCED, PLACE OF DIVORCE DECREE OAT/ OF ACREE. IF WIDOWED, PLACE SPOUSE DIED DATE SPOUSE DIED IF PREVIOUSLY MARRIED, INDICATE NAME(S) OF SPOUSE, REASON(S) FOR TERMINATION, AND DATE(S) APPROVED FOR RELEASE DATE: DEC 2007 3. MEMBERS OF FAMILY NAME OF SPOUSE ADDRESS (No., eat, City, Zone, State) TELEPHONE NO. M S OF CHILDR ` s cam ADDRESS SEX DATE OF BIRTH ' 9 NAME OF FATHER (Or male guardian) ADDRESS TELEPH-0 NO. NAM OF MOT ER (O fem a gu than) ADORES TELEPHONE NO. T, 'd WHAT MEM ER(S) OF YOUR FAMILY IF ANY, HAS BEEN T OF UR AFFILIATION WITH THE ORGANIZATION IF CONTACT IS RE- QUIRED IN AN EMERGENCY. 4. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY NAME (Mr., Mrs., M ss) (L' t-F'r t-Mfdd1e) RELATIONSHIP H ME ADDRESS (No., Street, City, Zone, State) ) ( J/~ HOM TELEPHONE NUMBER n 4)lp ,r,~ it h 1~ BUSINESS ADDRESS (No., Street, City, Zone, tale) AND NAME OF EMPLOYER, IF APPLICABLE BUSINESS TELEPHONE & EXTENSION IS THE INDIVIDUAL NAMED ABOVE WITTING. OF YOURAGENCY AFFILIATION? (If "No" givename and address of organize- YES Lion he believes you work for.) NO IS THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF? (If "Non give name and address of person, if YES . ., any, who can make such decisions in case of emergency.) p NO DOES THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE? (If answer is 'No' l i h i 6 YES exp n w y n item .) a NO The persons named in item 3 above may also be notified in case of emergency. If such notification is not desirable because of health or other reasons, please so state in item 6 on the reverse side of this form. CONTINUED ON REVERSE SIDE CURRENT RESIDENCE AND DEPENDENCY REPORT F 4-O60R M VL1 EUSDEITPIONRESVIOUS . CONFI TIAL (W Fi11ed In) CONJENTIAL 41 9fr CONF NTIAL (Wen Filled In) 5. VOLUNTARY ENTRIES Experience in the handling of employee emergencies has shown that the absence of certain personal data often delays and compli- cates the settlement of estate and financial matters. The information requested in this section may prove very useful to your family or attorney in the event of your disability or death and will be disclosed only when c irc uni stances warrant. INDICATE NAME AND ADDRESS OF ANY BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS AND THE NAMES IN WHICH THE AC- COUNTS ARE CARRIED. 1. Agency Credit Union (My name only) 2. Arlington Trust Company (Joint account with wife) Charles P. and Anne V.) HAVE YOU COMPLETED A LAST WILL AND TESTAMENT? ER YES = NO. (If "Yes" where is document located?) Safety Deposit Box Arlin h Trust Coma n Arlinrton, Va. HAVE YOU PREPLANNE,D AN ARRANGED GUARDIANSHIP OF YOUR CHILDREN IN CASE OF COMMON DISASTER TO BOTH PARENTS? t YES LI NO. (It 'Yes' give name(s) and address) in contents of will HAVE YOU EXECUTED A POWER OF ATTORNEY? (~7r7 YES = NO. (If 'Yes*, who possess the power of attorney?) ----++ My wife Mrs. Anne V Collins 6. ADDITIONAL DATA AND/OR CONTINUATION OF PRECEDING ITEMS SIGNED AT DATE SIGNATURE Washington, D, Cr 31 May 1961 CONFID54TIAL