[180-10060-10453.pdf — page 21]
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 liems 27 and 28 in the assached 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 sims of such organization of 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 of 28(a) above is in the affirmative stare 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?.|     |  X  |     || --- | :-: | :-: ||     |     |     |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 abere is "Yes," give details in Item 37. Show the name and address (including ZIP Code) of employer, approximate dan, and reasons in each case. This information should agra with your answers in liem 20, EXPERIENCE.|     |  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 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?.|     | N/A |     || --- | :-: | :-: ||     |     |     |If your answer to 32 of 33 is "Yea," give details in Item 37. Sbow for each offense: (1) date; (2) charge; (3) place; (4) court; and (3) action taken.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.).|     |     |  X  || --- | :-: | :-: ||     |     |     |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; sme; (2) present address (including ZIP Code); (3) relationship: (4) depart-ment, agency, or branch of the Armed Forces. If your anruer to 35 is "Yes," also give the kind of appointment held by the relative(s) you live with or beve lived with within the past 12 months.|     |     |  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 liems 26 through 36 above. Be sure you have placed an "X" to the left of EVERY marker() 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 ausmacement of position 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-StatementA teice answer to any question in this Statement may be grounds for not omploying you, or for dismasing you after you begin work, and may be punishable by fino or Imprisonment (U.S. Code, Title 18, Sec. 1001). All statements are subject to avestigation, Induding a check of your fingerprints, police records, and formar omployem. All the Information you givo will bo considsrod in reviewing your Statement and is subject to investigation. A false answer to Items 27 er 28 could deprive you of your right to an annuity when you reach ratirement age in addition to the penalHea described above.CERTIFICATIONI CERTIFY that all of the statements made in this Statement are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.![Signature]DATE SIGNEDMay 17, 1977Page 4NW 88326Docld:32239461 Page 22