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# SECTION XIFINANCIAL STATUS1. ARE YOU ENTIRELY DEFENDENT ON YOUR SALARY X YES NO2. IF YOUR ANSTER S "NO" TO THE ABCE STATE SOURCES OF OTHER INCOME3. BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS| NAME OF INSTITUTION           | ADDRESS (City, State, Country) || ----------------------------- | ------------------------------ || Monmouth County National Bank | Long Branch, New Jersey        |4. HAVE YOU EVER BEEN IN, OR PETITIONED FOR. BANKRUPTCY. YES X NO5. IF YOUR ANSWER IS "YES" TO THE ABOVE GIVE PARTICULARS, INCLUDING COURT AND DATE(S)6. GIVE THREE CREDIT REFERENCES IN THE UNITED STATES| NAME               | ADDRESS (No., Street, City, State)         || ------------------ | ------------------------------------------ || Eugene Anron       | 22 Community Drive, West Long Branch, N.J. || Lyman Horlik       | 114 W. 46 St., Bayonne, N. J.              || Abrahan E. Waldman | 235 Albert Pl., Elberon, N. J.             |7. DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT   ACT, PENSION, OR COMPENSATION FOR MILITARY OR NAVAL SERVICE YES X NO8. IF YOUR ANSDER IS "YES" TO THE ABOVE QUESTION, GIVE COMPLETE DETAILS9. DO YOU HAVE ANY FINANCIAL INTEREST IN, OR OFFICIAL CONNECTIONS WITH NON-U.S. CORPORATIONS OR BUSINESSES: OR IN   OR WITH U.S. CORPORATIONS OR BUSINESSES HAVING SUBSTANTIAL FOREIGN INTERESTS?YES X NO(If answer "YES", furnish details on separate sheet.)# SECTION XIIMARITAL STATUS1. PRESENT STATUS (Single, Married, Widowed, Separated, Divorced, or Annulled) SPECIFY: Married2.  June 9, 1950, Moscow, USSR, Irina Dosejeva, divorce, incompatability    Oct.12, 1954, Moscow, USSR, Eugenie Volsova, divorce, no childrenWIFE, HUSRAND If you have been married more than once including annulments - use a separate sheet for former wife orOR FIANCE: husband giving data required below for all previous marriages. If marriage contemplated, fill in appropriateinformation for fiance.|         | (First) | (Middle) | (Maiden) | (Last) || ------- | ------- | -------- | -------- | ------ || 3. NAME | Bella   |          | Milstein | Amron  |4. STATE ANY OTHER NAMES EVER USED   Bella Mincberg.   INDICATE CIRCUMSTANCES (Including length of time) UNDER WHICH ANY   OF THESE NAMES WERE USED. IF LEGAL CHANGE GIVE PARTICULARS   (Where and by what authority). USE EXTRA SPACE PROVIDED ON PAGE IS   OF THIS FORM TO RECORD THIS INFORMATION.|                                                                            |                                             || -------------------------------------------------------------------------- | ------------------------------------------- || 5. DATE OF MARRIAGE                                                        | 6. PLACE OF MARRIAGE (City, State, Country) || April 24, 1963                                                             | Long Branch, N. J.                          || 7. HIS FOR HER ADDRESS BEFORE MARRIAGE (No., Street, City, State, Country) |                                             || 260 Marshall Court, Long Branch, New Jersey                                |                                             || 8. LIVING X YES NO                                                         | 9. DATE OF DEATH NA                         ||                                                                            | 10. CAUSE OF DEATH NA                       || 11. CURRENT ADDRESS (Give last address, if deceased)                       |                                             || 260 Marshall Court, Long Branch, New Jersey                                |                                             || 12. DATE OF BIRTH                                                          | 13. PLACE OF BIRTH (City, State, Country)   || 1927                                                                       | Tomashuv-Maz, Poland                        ||                                                                            | 14. CITIZENSHIP U. S. A.                    |SECTION XII CONTINUED TO PAGE 10