[104-10225-10006.pdf — page 62]
SECRET# NOTIFICATION OF ESTABLISHMENT OR CANCELLATION OF OFFICIAL COVER BACKSTOP|                 |                                           || --------------- | ----------------------------------------- || DATE:           | 0 OCTOBER 75                              || FILE NO.        | 15675                                     || TC:             | X CHIEF, CONTROL DIVISION, OP             || (check)         |                                           ||                 | CHIEF, CONTRACT PERSONNEL DIVISION, OP    || SS NUMBER       | 460-45-0230.                              || EMPLOYEE NUMBER | 030130                                    || ID CARD NUMBER  |                                           || SEF:            | X CHIEF, (OPERATING COMPONENT FOR ACTION) || ATTN: LA        |                                           || Form 1322 Jated | 18 Aug 75                                 || STATUS          | X STAFF                                   || OFFICIAL COVER  | X ESTABLISHED                             ||                 | CANCELLED                                 || SUBJECT         | CONTRACT UNIT                             |DEPARTMENT OF STATE# KEEP ON TOP OF FILE WHILE COVER IN EFFECT| ESTABLISHMENT OF OFFICIAL COVER (BLOCK RECORDS)                                                | CANCELLATION OF OFFICIAL COVER (UNBLOCK RECORDS)                    || ---------------------------------------------------------------------------------------------- | ------------------------------------------------------------------- || X BASIC COVER PROVIDED EFFECTIVE DATE: EOD                                                     | EFFECTIVE DATE:                                                     || OPERATIONAL COVER PROVIDED FOR TOY OTHER (Specify)                                             | SUBMIT FORM 3254 (NHB 20-7) W-2 TO HE ISSUED                        || X SUBMIT FORM 642 IMMEDIATELY TO CHANGE TELEPHONE LIMITATION CATEGORY TO CATEGORY 3 (NN4 20-7) | SUBMIT FORM 642 IMMEDIATELY TO CHANGE TELEPHONE,                    ||                                                                                                | LIMITATION CATEGORY TO CATEGORY (NN4 20-7) 5                        || X SUBMIT FORM 3254 State W-2 TO BE ISSUED. (NHB 20-11)                                         | EAA CATEGORY I CATEGORY II RETURN ALL OFFICIAL DOCUMENTATION TO CCS || X SUBMIT FORM 1322 FOR ANY CHANGE AFFECTING THIS COVER. (HR 240-20)                            | SUBMIT FORM 2688 FOR HOSPITALIZATION CARD.                          || X SUBMIT FORM 1321 FOR TRANSFERRING COVER RESPONSIBILITY. (NR 240-20)                          |                                                                     || X EAA, CATEGORY I A CATEGORY II N                                                              |                                                                     || X SUBMIT FORM 2688 FOR HOSPITALIZATION CARD                                                    |                                                                     || 12 Mar 62-2 Dec 67-Hqs-Overt                                                                   |                                                                     || 3 Dec 67-9 Apr 69-Hqs-DAC                                                                      |                                                                     || 10 Apr 69-May 71-Ecuador-State-Int.                                                            |                                                                     || May 71-Sep 71-II/I. 6 Tdy-State-in.                                                            |                                                                     || Sep 71-Mar 74-Peru-State-Int.                                                                  |                                                                     || Mar 74-13 Sep 75-Hqs-State-Int.                                                                |                                                                     || 14 Sep 75- -Hqs-State-Nominal                                                                  |                                                                     |![Signature]