[180-10060-10453.pdf — page 43]
ANSWER ITEMS 26 THROUGH 36 BY PLACING AN "X" IN THE PROPER COLUMN26. Are you a citizen of the United States?.................................................................................................................................    If "No." give country of which you are a citizen:|     | Yes | No  || --- | --- | --- ||     | X   |     |Before answering these questions read Items 27 and 28 in the attached instructions.27. Are you now a member of the Communist Party, U.S.A., or any subdivision of the Communist Party, U.S.A.?...................................|     |     | X   || --- | --- | --- |28. (a) Are you now, or within the last ten years have you been, a member of any organization, or group of persons including but not limited    to the Communist Party, U.S.A., or any subdivision of the Communist Party, U.S.A., which during the period of your membership you knew    was advocating or teaching that the government of the United States or any political subdivision thereof should be overthrown or overturned by    force, violence, or any unlawful means?......................................................................................................................................................|     |     | X   || --- | --- | --- |28. (b) If your answer to (a) is in the affirmative, did you, during the period of such membership, have the specific intent to further the aims of    such organization or group of persons to overthrow or overturn the government of the United States or any state or any political subdivision    thereof by force, violence, or any unlawful means?......................................................................................................................................................|     |     | X   || --- | --- | --- |29. If your answer to 27 or 28(a) above is in the affirmative state the names of such organizations and the dates of your membership in each in    item 37.30. Within the last five years have you been fired from any job for any reason?....................................................................................................31. Within the last five years have you quit a job after being notified that you would be fired?..................................................................................    *If your answer to 30 or 31 above is "Yes," give details in Item 37. Show the name and address (including ZIP Code) of employer, approximate date, and    reasons in each case. This information should agree with your answers in Item 20, EXPERIENCE.*|     | X   |     || --- | --- | --- ||     | X   |     |32. Have you ever been convicted of an offense against the law or forfeited collateral, or are you now under charges for any offense against the law?    (You may omit: (1) traffic violations for which you paid a fine of $30.00 or less; and (2) any offense committed before your 21st birthday which    was finally adjudicated in a juvenile court or under a Youth Offender law.).................................................................................................................|     | X   |     || --- | --- | --- |33. While in the military service were you ever convicted by general court-martial?.................................................................................................    *If your answer to 32 or 33 is "Yes," give details in Item 37. Show for each offense: (1) date; (2) charge; (3) place; (4) court; and (5) action taken.*|     |     | n/a || --- | --- | --- |34. Does the United States Government employ in a civilian capacity or as a member of the Armed Forces any relative of yours (by blood or marriage)?    (See Items 34 and 35 in the attached instruction sheet.).........................................................................................................................................35. Do you live with, or within the past 12 months have you lived with, any of these relatives who are employed in a civilian capacity?................    *If your answer to 34 is "Yes," give in Item 37 for such relatives: (1) full name; (2) present address (including ZIP Code); (3) relationship; (4) depart-    ment, agency, or branch of the Armed Forces. If your answer to 35 is "Yes," also give the kind of appointment held by the relative(s) you live with or have    lived with within the past 12 months.*|     | X   |     || --- | --- | --- ||     | X   |     |36. Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based upon military, Federal    civilian, or District of Columbia Government service?........................................................................................................................................    *If your answer is "Yes," give details in Item 37.*|     | X   |     || --- | --- | --- |Your Statement cannot be processed until you have answered all questions, including Items 26 through 36 above. Be sure you have placed en "X" to the left of EVERYmarker (◄) above, either in the "Yes" or the "No" column.37. Space for detailed answers. Indicate Item number to which answers apply.    Item No.If more space is required, use full sheets of paper approximately the same size as this page. Write on EACH sheet your name, birth date, and announcement orposition title. Attach all sheets to this Statement at the top of Page 3.ATTENTION - THIS STATEMENT MUST BE SIGNEDRead the following paragraph carefully before signing this-RatementA felce answer to any question in this Statement may be grounds for net omploying you, or for dismasing you after you beginwork, and may be punishable by fine or Imprisonment (U.S. Code, Title 18, Sec. 1001). All statements are subject to investigation,Induding a check of your fingerprints, police racords, and former employers. All the Information you givo will be considered inreviewing your Statement and is subjaet to Investigation. A false answer to items 27 or 28 could deprive you of your right to anannuity when you reach retirement age in addition to the penalties desertbed above.CERTIFICATIONI CERTIFY that all of the statements made in this Statementare true, complete, and correct to the best of my knowledgeand belief, and are made in good faith.Page 4SIGNATURE (Sign in ink)![signature]DATE SIGNEDMay 17, 1977![numbers]NW 88326Docld:32239461 Page 44