HR - APPOINTMENT AFFIDAVITS - KLIPA, EDMUND X.

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0005461829
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 24, 2015
• Document Release Date: August 26, 2010
• Case Number: F-2009-01528
• Publication Date: August 21, 1950

STANDARD FORM 61 (REVISED AUGUST 1949)
PROMULGATED BY CIVIL SERVICE COMMISSION
APPOII TMENT AFFIDAVITS
IMPORTANT.-Before swearing to these app-ointmentaffidavits, you should read and understand the
attached information for appointee
------------ -------------------------------------- ;-- ------ ---------------- ----------------- -----=------------ -------------
(Department or agency) (Bureau or division) (Place of employment)
CIA I&S
Edmund X, K].ipa -___ do solemnly swear (or affirm) that-
A. OATH .OF OFFICE
I will support and defend -the Constitution of the United States against all enemies, foreign and
domestic that I will bear true faith and allegiance to the same; that I take this obligation freely
without any mental reservation or purpose ofevasion; that I will well and faithfully discharge the
duties of the office on which I am about to enter, SO HELP ME GOD.
& AFFIDAVIT AS TO SUBVERSIVE ACTIVITY AND AFFILIATION
I am not a Communist or Fascist.'-' I do not advocate nor am I a member of any organization
that advocates the overthrow of the Government of the United States by force or violence or other
unconstitutional; means or seeking by' force or violence to deny other persons their rights under the
'Constitution of the United States. I do further swear (or affirm) I will not so advocate, nor will
-1, become a member of such organization during the period that I am an employee of the Federal
`Government.
C. AFFIDAVIT AS TO STRIKING- AGAINST THE FEDERAL GOVERNMENT
an organization.
so engage while an employee of the Government of the United States; that I am not a member of
an organization of Government employees that asserts the right to strike against the Government
of the United States, and that I will not, while a Government employee, become a member of such
I ani'not engaged in any strike against the Government of the United States and that I will not
D. AFFIDAVIT AS TO PURCHASE AND SALE OF OFFICE
I have not paid, or offered or promised to pay, any money or other thing of value to any person,
firm or corporation for the use of influence to procure my appointment.
E. AFFIDAVIT AS TO DECLARATION OF APPOINTEE
The answers given in the Declaration of Appointee on the reverse of this form are true and
correct.
(__,
Subscribed and. sworn, before me this _____2 day. of ____________________ -A. D. l o___
NOTE.-If the oath is taken before a Notary Public. the date,of, expiration of his commission sou
APPROVED FOR -
RELEASE^ DATE:
12-Jul-2010
shown.
 DECLARATION OE-APPOINTEE
This form is to be completed before entrance on duty. Answer all questions.. Any false statement in this
declaration will be grounds for cancellation of application or dismissal after appointment. Impersonation is 'a
criminal offense and, will be prosecuted accordingly.
1 2 To1' i ^ p.:, d ,
Iian.v?_r c , c'_; c"tJEet ts
-i` J (B) PLACE OF BIRTH (cityor town and State or country)
r s . e ?.en A ire 13 or s T.o.= e , :aver
(D) TELEPHONE NO.
ar tr__
_7T
~,usetts 2086
4. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN
THE PAST 24 MONTHS? YES ? NO
If so, for each such relative fill in the blanks below. If additional space is necessary, complete under Item 10.
NAME
POST OFFICE ADDRESS
O) POSITION (2) TEMPORARY OR NOT
(3) DEPARTMENT OR AGENCY IN WHICH
RELATION-
MAR' I
RIED
WNGLE
(Give street number, if any)
EMPLOYED
SHIP
?------------------------------------------
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-
------------------------------------------
.:
2?-----------------------------------------
3
INDICATE "YES" OR "NO" ANSWER BY PLACING "X"
10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS
' ".. -IN PROPER COLUMN
YES
NO
ITEM
NO
WRITE IN LEFT COLUMN NUMBERS OF ITEM'S TO WHICH DETAILEDANSWERS APPLY
._ .. ,. _ . ....
S. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIAiiCE TO THE UNITED STATES?__
-
x
-
-
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------
-------------- - --------------- -------- ------- -----------------------
- : - - - - -
---------------------------------------------------------- -----------------------
5. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY. COUNTY, OR
______
-------------------------------------------------- _ --------- ______-_______-_
MUNICIPALITY ?_; _-___ _____________ -
X.
If yourenswers "Yes"; give details in Item 10.
------- ------ --------- - ----- ------ ---------------
7. DO YOU- RECEIVE ANY ANNUITY FROM THE UNITED STATES OR DISTRICT OF
-
---
------
----------------------------------------------------------------------------------
COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACTOR ANY PENSION.OR
'-'---
------ ---- -' ----r-
-------------------------------------------------- -------
--
-
OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE? ______ -
-
-
-
- - `- '- "- -
:- -. -
If youranswor is "-Yes", give in Item 10 reason for retirement,
------
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- ~ - , ;
that `is, age, optional disability,, . or by reason of voluntary
______
__
----------- _________ ________ ________ _________ _______
or involuntary separationafter ?years' service; amount of
__ _____
_
- .
retirement pay; and under what retirement act; and rating,
_
_____ _____
if retired from military or naval service. ,
__ ____- _.--___
I. SINCE YOU FILED APPLICATIONRESULTING IN THISAPPOINTMENT HAVE YOU
BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR UNSATIS-
FACTORY SERVICEPROM ANY POSITION?-__ ______________- ___________
Zfyour answer ss "Yes", ivo in Item 10 the name and address
:
of employer, date and reason in each case.
--------------------------- 7------------------------------------------ ----------
x.
---
HAVE YOU:-BEEN ARRESTED (NOT INCLUDING TRAFFIC VIOLATIONS FOR
-
.
-----
--------------------------------------
------ --------- ?-----
WHICH YOU'WERE FINED $25 OR LESS, OR FORFEITED COLLATERAL OF $25 OR
-
- - - - - - '
-----
-
-
LESS) SINCE-YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT7._,
-----
-
-
-'----- -
-
----- -------- -------- -------
--1 --------- --
~- - - ~ -,---
Zf
our
answer is "Yes", list all such cases under Item 10.
-------
_ - ---------- -' '-"'-
Give
each c
ase: (I) The date; (2) the nature of the offense
or violation; (3) the name and location of the court; (4) the
----- ---`-'" -
penalty imposed, if any, or other disposition of the case.
-'---------
If appointed, your fingerprints will be taken.
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-- - ------------------
- .. ._c
J .1. x
~
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INSTRUCTIONS TO APPOfl4T6NG OFFICER
The appointing officerbeforewhom the foregoing certificate is madeshall
determine to his own satisfaction that this appointment would be in conformance
with the Civil Service Act, applicable Civil Service Rules and Regulations and
acts of Congress pertaining to appointment.
This form should be checked for holding of office, pension, suitability in con-
nection with any record of recent discharge or arrest, and particularly for the
following:
(1), Identity of appointee.-It is the duty. of the appointing officer to
guard against impersonation and to determine beyond reasonable doubt that the
appointee is the same person whose appointment was authorized. The
appointee's signature and handwriting are to be compared with, the application
and/or other pertinent papers. If the appointee quajifiedin a written exami-
nation, the signature on this form should he compared with 'the' signature on
the declaration sheet, which was signed in the examination room. His physical
appearance may bechecked against the medical certificate. The appointee
may; also be questioned on his personal history for agreement with his previous
statements.
(2) Age.-If definite age limits have been establishedfor the position, it should
be determined that applicant is not,outside the age range for appointment.
Until such determination is made, the appointment may not be consummated.
(3) Citizenship.-The appointing officer is responsible for observing the
citizenship provisions of (1) the Civil Service Rules and (2) appropriation acts.
Form 61 constitutes an affidavit for both purposes and is acceptable proof of
citizenship status in the absence of conflicting evidence- In doubtful cases the
appointment should not be consummated until clearance has been secured from
thecertifying office of the Civil'Service Commission,'
(4) Members of Family.-Section 9 of the Civil Service Act provides that
whenever there are already two or more members of a family serving under
probational or permanent appointment in the competitive service, no other
member of such family is eligible for probational or permanent appointment in
the competitive service. The appointments of persons entitled to veteran
preference are not subject to this requirement. The members-of-family provision
does not apply to temporary appointments. Doubtful cases may be referred to
the appropriate office of the Civil Service Commission for decision.