“(Please provide copies of any trust or other agreements.) not applicable”
(EST PUB DATE) ARRB-BOARD/SPECIFIC INFORMATIONp. 76source: semanticDerived signal64%
HSCA REQUEST (INDIVIDUALS AND ORGANIZATIONS).
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“(Please provide copies of any trust or other agreements.) not applicable”
“tor.) YES |X NO i -— Yes ------------------------------------------------------------------------------------------------------ IS THIS INDIYIOUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (I0 "No" give name and address of person. If any, wh”
“AUTHORIZED TO MAKE DECISIONS on you SERALF IN THE-EVENT YOU ARE INCAPABLE? (80 No” NO YES' $1 *0 name and oddrona of person, le eny. who can make such dnclatz 2 casa of seneraincr) 1 NO DoF: THIS INDIVIDUAL KNOT THAT HE HAS ODEN OR3I0N41EC AS • CUR EMERGENCY ADORESSEE? '(i”
“1 1-00000 Z *.e : SECRET (When Filled In) SECTIC# • CONTINUED FROM PAGE 2 4. wave vou tven oftt Im, on PETITIONED (os, BA0,#UPTCYt D4 9. IF YOUR A95 L0 it “ves” TO THE 400 V8 Qutstipe, CIVE PARTICULARS, INCLUDING COURT AND DATE4 S) 6. NA 00 You RECEIVE AN ANNUITY F”
“of birth (Cay. State, Country) (2), 3 Cimsenship (Country) • Address (Number, Street, Coty. State, Covatry) - / Type and location of service fit knowe) % j I Nemo tlov - for - b.ddie) 2 Belaherab-p 3 Date of birth 4 Place of birth (City. Srate. Country) (3) $ Citserahip (C”
“YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATED WITH ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE AS AN AGENT. OFFICIAL. OR EMPLOYEE? X ARE YOU NOW ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS. INCLUDING RELATIVES, WHO YOU KNOW OR HAVE REASON TO BELIEVE,”
“OF THE U. S OR OF A FOREIGN GOVERNMENT: 1. NAME. N.A. RELATIONSHIP e AGE.. crrizkNsui". ADDRESS .... (5€. and Number) ■ (019) (State) (Constry) TYPE AND LOCATION Or SERVICE UP KNOWN) 2. NAME.... .... RELATIONSHIP.... AGE . CifizENsuP ... ADDRESS lilt, at Number): (Cn”
“NAMED AsovE WITtino or YOu AGENCY AFFILIATION? (18 "No” Give name and addross of organisa- (lop ""** * • * 808.) YES NO Lawyer a Secure Denali Mrs Lone Oflawintemay-malie 15 Twis ICIVOUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BfnALF Ih racy EVENT you ARE INCAPABLE? cze "No ”
“1*3 nry:4 AUTHORIZED TO laK pacicus ON roun a wau * ThA Ehyt YOU ARE IhcApasLe* rae “No” "9 dents are wo.ee* c! pers.ar, tf any who eon 0.«>« sauh jeciativia M 4>xo ot aeergency.) 10 b■ AU RNOT FAAT NE *5 dt** ctstanATAu A 1 TOR exann UagEk! -a ** {A Pha perians nameed u. ”
“INDICATE THE WAWE OF THE AGENCY AND THE APPROXIMATE DATE CE YeE INVESTIGATION. IA NA it mbamunt e * i* t* n * t* G S • 4 5 :5 NOTE SPECIAL H your answer is YES" t the following Grestions 10. 11 or 12, provide the information requested for ooch UTRUCTIONS, Goostion on a sapo”
“INCAPADLE’ the s.° give nan.e an a added a of farin', tt any, who tan mob o such Jocielana bi toes o eeerosr.); 0005 Press DIVDusL ahQe Thar HE was GeN Ca1i0N*190 as rouN BUCNOENCT Domesse# fit e.. saplaws ** to item 2 The persons nomed is it- 3 obev. »y7 eiso ba notified t”
“AFFILIATION’ - (0 "No" give name and address of organize- ton he believes you work tot) YES NO IS THIS INDIVIDUAL AUTHOR ED 1 O MAKE DECISIONS ON YOUR BEHALF’ (If "No” give name and address of person, it any, who can make such decisions in case of emergency.) YES NO DO”
“wedse so state in item 6 on the reverse side of this form, vie : CONTINUED ON REVERSE SIDE CURRENT RESIDENCE AND DEPENDENCY REPORT FORM A1 0*6 paC.9.9 (4) 4.40 01 EO:T/O=%. CONFIDENTIAL SECRET PART II i 1,- - 25 AC AND DISTRIBUTE SEPARATELY petiC: ZhiS POR TION OF FOR”
“GXT6NSO4” NONE is THE NOTViDUAL NAMBO’anovE wit i ING or YOUR AGENCY APPICiAroNt aleo° give name and aindene of organisos Net tr.n 00 belteves’yrw won No .--AIS ICIVOVAL AUTNORegp 10 WKKK DECISIONS OH,YOUR BEHALF G.THEvEHy YOU ARE INCAPABLEN !R NeP give name andledwess of ”
“set was of person, If any, who ton make mech I- cetetousa ‘‘lre Trk Everey 100 Auk st emergency.) U’ tte " Tex 1 DOEE 1H13 *V:Qu*L • RE M2 nEft Desi FtD A9 YOUR EMERGENC « 00625% ? (ze efipou esplain whr tey atom 6.) X The persons named in tee 3 ctovo may also be not.h.ed”
“1, MEMBERS OF FAMILY *9E Of.sPOyS ADDRESS (Vo.. Street, City, Zone, State) LOUISE HIDALGO TELEPHONE NUVSER NAMES or CHILORSN annRrss sex F Luz MARIA **/3 9 FRANCES REBECCA Balmes N Hidalgo VAME OF FATHER (Or note @uordson) ADDRESS TELEPHONE NUMBER cr MOTHER (Or femal”
“ENTIRELY DEPENDENT 0% roav SALAD? Lrilres 2,00 YOU HAVE ANY FINANCIAL INTEREST se. CR OFFICIAL CONNECTION wIt+, NON-U.S. CORPORATIONS C° *:51466565 CR IN 09 NO WITH U.S. CORPORATIONS OR 809.95589 waVIno LUBS ANTAL FOREIGN INTERESTS? YES IF YOU HAVE ) ANSWERED "YES." GIVE C”
“FAMILY, AND ASSOCIATES . • :0 13. OTHER SIGNIFICANT DATA (POLITICS, RELIGION, ETC) ATTACH EXTRA SHEETS WHEN NEEDED INSERT CARBON: FILL OUT FORMS COMPLETELY. INSTRUCTIONS: SEND BOTH SHEETS TO FI/D. SEE CS1-10-7 FOR ss-sa 50 use pecvroun rerrsons. SECRET (9) Jtsrhnikoix”
“NOT IED tee ratl 2* LV1PGENCY. IF SUCH NOTIFICATION 15 NO. DESIPAGLE BECAUSE OF MLALTH 09 GTVIER REASONS, PLTASE to STATE A :TE % 7 &% : -E P,ER5€ SIDE CF tselS FORM. 5. VOLUNTARY EUT IES Suburban Trust Co, Bethesda Br. INDICATE ay BANKING INSTITUTIONS WITH DrICe YOU HAVE AC”
“work tor.) - ; - YES Yes IS T 15 INDIVIDUAL AUTHORIZED TO MARE DECISIONS ON YOUR BEHALF’ (It "No” give name and achtroue of person, if NO tit case of emergency.) any, who can make such decisions tza VES : NO POE% THIS INDIVIDUAL KNOW THAT HE HAS BEPN DESION A TED AS YO”
“-00000 50 PERSONAL RECORD QUESTIONNAIRE SECRET " PRO BO. .... PART II - OPERATIONAL INFORMATION Bi*tC* h* NVCA-18757 INSTRUCTIONS ro CASE OFFICER This fore oust be filled in by the case officer or appropribke authority on the Basis of the Sect available in formation. ”
“INDIVIDUALAUTHORISED TO make DECISIONS ON YOUR nenALne EVENT You ARE INCAPABLE? (ze Non YES Nathaniel Cohen 333 Central Park West, Now York, N. Y. give name and aul.fress ol person, I/ any, who can make such declalons Incase of emergency.) NO De OCE3 TH INDIVIDUAL KNOWTHAT ”
“L RECORD QUESTIONNAIRE PART 11 OPERATIONAL INFORMATION INSTRUCTIONS TO CASE OFFICER DISPATUFCA-19738 Thee form must be filled in by the case officer of appropriate authority on the basis of the best available in formation. It is not to be shown to the subject. 2. Vormally, headqu”
“YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (It "No" : Vee: give name and address of person, it any, who can make such decisions in case of emergency.) , YES IN° * DOES THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE* (It answeri.No ezplan any tr”
“soun qanALe IN rhu f VCNT YOU Anu INCAPABLE, fit “No° give n mo a and s00e 1 el moreen, i* any, who 6.7 nase owe" dodlelune be sees of emergence) NO Dv** t * EN0O inav HE was nest besignatso • • rove *MBRORCy sbuneusse 1## anomer t» NG" ""LI A No. The poroono nomel in wee”
“or those of your close reiztices in such orcanmations, including the names of the organizations, dates of membership, meetings attended, piles of positions held, amounts and dates of contributions, nature of petitions signed falling within the meaning of the above certification”
“AGE it CITIZENSHIP ADDRESS _ . ./ . . SL & NO. City‘ State TYPE AND LOCATION OF SERVICE (IF KNOWN). 5”
“14-00000 !: Til / - ,,.t,"it, (.e%; 218 CTI0V ). HOSPITALIZATION AND CURGICAL GROUP POLICY ICANeT Fug Uf F?pf"f7a evnvi FI" jI: ede ferate "! "_ Married roe .".,"hiirznt 2. save /Gu any deformities or impairments of health? If jus, tive Cor: eto details 3. eetiwer 70”
“OUTSIDE OF THE UNITED STATES Ka NA NH A 1 A.FROM .... TO____ (City or section I (Country) (Purpose) FROM ..... - TO- (City or section) (Country) (Firposo) FROM . ...... TO.. (City or section, (Country) (Purpose) FROM FROM VA TO ... TO____ (City or section) (Countr”
“GENERAL TERMS SUCH AS "DEROGATORY" MAY RESULT 1* A SEARCH THAT DOES NOT FULLY MEET REQUIREMENTS.). Any information except basic biographic and/or occupational . data since previous Green List, No 125246, dated 5 Sep 62.[ INSERT CARBON: FILL OUT FORMS COMPLETELY. INSTRUCTIO”
“OF SERVICE OP KNOWN) 2. NAME RELATIONSHIP AGE CITIZENSHIP ADDRESS 8t. e: tto. Cur TYPE AND LOCATION OF SERVICE (IF INOWN) .3. NANS RELATIONSHIP AGE CITIZENSHIP ADDRESS Bt & No. City State TYPE AND LOCATION or SERVICE Jr KNOWN 5 1”
“name and nidreen ct organiza- ton he believes you work tos.) ' VEs VES THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (ft "No” NO give name estel addroan ol peroori, it nny, who can make such doctalona dr case of emergency.) (E”
“questionnaire as thoroughly and accurately as possible and returning it to your Administrative Officer within the time allotted. CODED J1 -OR gil H- Wo George E. Melon SECRET Security Information may so, 1, Ft 1982 182 37-182 h-::i 'I■ welveninyade”
“(89 "No" give name ard address of organiaa- tion he believes you work lor.) - . ves NO IS THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF! ftt “No” give name and oddroca of poeeon, it ves any, who can make such decisions in case of emergency.)' wife NO DOES TH”
“he boltoves you wash for.) YES € NO • Ticis IDIOUAL AutsoNIzED to WIRE DECIION4 on roUR BEHALF’ (It "No" qive neme and addenun al porsori, if VES any, who son trek a such decisions try Caso ct emorgen-y.) NO Dose TH DJDOAL KNCE TASiRR HAG 06Ex BRMONATEO AS YOUR EURAJENIT A”
“Number) (State) (Country) TYPE AND LOCATION OF SERVICE (IF KNOWN) ..... 2. NAME__ VA ...... RELATIONSHIP.... NA ....AGE NA 14 MM CITIZENSHIP ___ ADDRESS. "(Sc. and Number) (Clip) (State) (Country) NA 3. NAME _____ ; NA ... RELATIONSHIP- VA ... AGE LA CITIZENSHIP ...”
“14-00000 y,2v00-r0jrl1iNANClALlrstrinniPeryit mibonan CALL DERTG IN- 0,If %‘. DAdl HAVE YOU EVER s> ,e‘, 43:080 (0(07 AlY, ._Iso I, a*set. IS vor ,T4TL N*DP TTLM 03? THE A 0.5. 66M ‘ _ Jiit TI5", QNO IF 1% / SAME 3 or CE011045, AMOUNTS DUE 10 EACM, Aul, LATE, 09 WHICH THE I”
“TO Voun KNOWLEDGE, ANY OF fir Anovr. HAVE CONDUCTED AN INVESTIGATION OF YOU, INDICATE THE NAME OF THE ACENCY AND THE APPROXIMATE DATE OP THE INVESTIGATION. • CSS 1943 U.S. Arrer 1956-57 A 350 1946 ACSI D of A 1959 010 1947 CIA 1948 49 NOTE SPECIAL If your answer la "YES"”
“14-00000 % (14) F. IF, TO YOUR KNOW EDGE. ANY OF THE ABOVE HAS CONDUCTED AN INVESTIGATION OF YOU, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION: .1 29o2..Invoudi;fion ugact, 040... SEC. 26. PERSON TO BE NOTIFIED IN CASE OF EMERGEN”
“is THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONSON YOUR BEHALF (ze "No” give name and address of perea it' YES any, who can make such dectslona ors case of emergency.) X I No DOFS THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE? (It answer >»° YES”
“FULL NAME (Last-First-Middle) 2. RELATIONSHIP 3. AGE 4. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES 5. EMPLOYED BY 3 6. CITIZENSHIP (Country) 7. FREQUENCY OF CONTACT 8. DATE OF LAST CONTACT 1. FULL NAME (Last-First-Middle) 2. RELATIONSHIP 3. AGE 4. ADDRESS OR COUNTRY IN”
“14-00000 % SECRET r when Filled In) SECTION V CONTINUED FROM PAGE 2 a.mavevou zytn wren IN. OR PETIVIONr? son. BAN*mpPrcy , ]_ | Hi IXT 9. If YOUR anteER is "ves" 10 ths ABOSE QUESTION. Give PARTICULARS, INCLUDING count AND pATFIS) • 00 YOU DECEIVE AN ANNUITY FROM THE UN”
“WHICH RELATIVE #:91015 4 s. CITIZENSHIP (Country) 6. FRCQUrNrV Or CONTACT /. DATE OF LAST CONTACT B. SPECIAL NEMARKS, i/ ANY, CONCERNING THESE NrLATIVES SECTION V FINANCIAL STATUS L. ANE YOU ENTIRELY Dt PENDE NT ON YOUR SALARY? XTas 7. DO YOU HAVE ANY I INANCIAL INTERI ”
“AGENCY AND THE APPROXIMATE DATE OF THE INVESTIGATION. 1 NOTE SPECIALIf your answer is * ES” to the following Questions 10, 11 or 12, provide the information requested for each INSTRUCTIONS I question on o separate, signed sheet and attach the sheet to this form in a sealed e”
“record up to date. - war 3. Your cooperation is requested in completing the questionnaire as y r- thoroughly and accurately as possible and returning it to your Administrative Officer within the time allotted.. George E. Melon SECRET Security Information FORM NO. 47 .”
“3. NAME — RELATIONSHIP - AGE CITIZENSHIP ADDRESS et nBo. City State TYPE AND LOCATION OF SERVICE (IF KNOWN)- 5 «”
“M2ESTLATTOR, WItt THOR YOU Wety DIRECTLY INVOLVED OR NOT. WHICH MISItT REQUIRE EX- • PLANATICN' IF 50, DESCRIBE BNCIOHNrls) AND PROVIDE DATE15) OF OCCURRENCE ON SEPARATE SH2E1 IN AC- CORDANCE Nilre SPECIAL INSTRUCTIONS ABGvE. x No SECTION XXY__________ PERSON TO BE NOTIFIED I”
“vov vas Dorothy A. Flores (Spare) give same bid a-Ktress of peroor, *9 an r. who can make such teclelane to Case of emergency.) 06%, this INDIVIDUAL inov THAT ME seas BEEN DESIGNATED AS VOUN EMERGENCY ADOMGSeGR ill anewe, le No* esp/ain sA, • itemn 6.) NO ivr)J No . T”
“14-00000 a 0 27. Habilidades especiales, oapacidades, aficiones, (radio, fotogra- fia, oto.) mone 28. Situation monetaria - sueldo, depdsitos en los banoos, bonos, pro- piedades. 29. Datos de empleos - olase de trabajo, sueldo, fechas, patrones, di- recoiones, razones”
“ANSWER IS "YES," GIVE DETAILS BELOW: E. LIST BELOW THE NAMES OF GOVERNMENT DEPARTMENTS, AGENCIES OR OFFICES TO WHICH YOU HAVE AP1IB9R‘21985**25*8991- tion U. 0. Civil nevvteo emission (13) to cats- T‘ye"Easkor”