[104-10194-10026.pdf — page 279]
# CERTIFICATIONI certify that I have read the names of the above listed organizations.To the best of my knowledge and bellef, I am not, nor have I been a member of, contributed to, received liter-ature from, signed petitions of or in behalf of, or attended meetings of any organization listed above, or any organisation outside the United States espousing Communist, Fascist, Totalitarian or Nazi causes, except as noted below.To the best of my knowledge and bellef, none of my close relatives are, nor have ever been members of, con-tributed to, received literature from, signed petitions of or in behalf of, or attended meetings of any such organiza-tions, except as noted below.# INSTRUCTIONSFor the purpose of this certification, if an applicant or employee is completing this form, the term "close rela-tire" will include spouse, children, parents, brothers, sisters, uncles, and aunts. "Close relatives" of the spouse, for this parpose, will include children, parents, brothers, sisters, uncles, and aunts.If there are exceptions to this certification, set forth below under Remarks all pertinent information concern-ing the nature and extent of your activities or those of your close relatives in such organizations, including the names of the organizations, dates of membership, meetings attended, titles of positions held, amounts and dates of contributions, nature of petitions signed falling within the meaning of the above certification and circumstances thereof, tities and authors of literature received, and dates on which received.In erceptions concerning relatives, include only such information presently known to you or available from your own records.If necessary, use additional sheets and sign each sheet. Write none if there are no exceptions.| REMARKS: To be completed by Spouse | REMARKS: To be completed by Applicant or Employee || ---------------------------------- | ------------------------------------------------- ||                                    |                                                   ||                                    |                                                   ||                                    |                                                   ||                                    |                                                   ||                                    |                                                   ||                                    |                                                   ||                                    |                                                   ||                                    |                                                   || Date                     | Date                               || ------------------------ | ---------------------------------- ||                          | March 12, 1969                     || Signature of Spouse      | Signature of Applicant or Employee ||                          | Urgenica A. Ahern                  || Address-City and State   | Address - City and State           ||                          | Retornac, Thailand                 || Witress                  | Witness                            ||                          |                                    || Address - City and State | Address City and State             ||                          |                                    |-4-