14-00000
104-10110-10291
TO:
(Check)
2025 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992
NOTIFICATION OF ESTABLISHMENT OR CANCELLATION
OF OFFICIAL COVER BACKSTOP
X CHIEF, CONTROL DIVISION, OP
CHIEF, CONTRACT PERSONNEL DIVISION, OP
(OPERATING COMPONENT FOR ACTION)
DAT
29040
..
28 DECEMBER 1977
SS NUMBER
FILE NO.
3190
069-26-3138 RETURN TO CIA
EMPLOYEE NUMBER Background Use Only
007667 
*Do Not Reproduce
ID CARD NUMBER.
REF
X
CHIEF
ATTN:
RETIREMEN
STAFF
CONTRACT
ESTABLISHED
OFFICIAL
COVER
CANCELLED
CONTINUED
UNIT
DEPARTMENT OF STATE
STATUS
SUBJECT
BUSTOS VIDELA CHARLOTTE
KEEP ON TOP OF FILE WHILE COVER IN EFFECT
X ESTABLISHMENT OF OFFICIAL COVER (BLOCK RECORDS)
ii 』se:
BOD
✗ BASIC COVER PROVIDED
EFFECTIVE DATE.
OPERATIONAL COVER PROVIDED
3.
+
CANCELLATION OF OFFICIAL COVER (UNBLOCK RECORDS)
EFFECTIVE DATE:
FORM 3254
W-2 TO BE ISSUED
FOR
TDY
. OTHER (Specify)
SUBMIT FORM 642 IMMEDIATELY TO CHANGE TELEPHONE
LIMITATION 
CATEGORY TO CATEGORY_
X (HHB 20-7)
(HHB 20-7)
SUBMIT FORM 642 IMMEDIATELY TO CHANGE TELEPHONE
LIMITATION CATEGORY TO CATEGORY_
(HHB 20-7)
EAA: CATEGORY. I
CATEGORY 11
RETURN ALL OFFICIAL DOCUMENTATION TO CCS
_W-2 TO BE ISSUED.
(HHB 20-11) --
94
X FORM 3254 C
X SUBMIT FORM 1322 FOR ANY CHANGE AFFECTING THIS
COVER. (HR 240-20)
SUBMIT FORM 1323 FOR TRANSFERRING COVER
RESPONSIBILITY. (HR 240-2€)
SUBMIT FORM 2688 FOR
HOSPITALIZATION CARD.
DO NOT WRITE IN THIS BLOCK
EAA. CATEGORY I
ན་
CATEGORY 11
X SUBMIT FORM 2688 FOR AND HOSPITALIZATION CARD
REMARKS AND/OR COVER HISTORY.
SUBJECT WILL BE DENIED FOR INTIRE PERIOD OF EFLOYMENT EXCEPT FOR US GOVERNMENT
APPLICATIONS.
DISTRIBUTION:
COPY 1 - CD/TRB OR CPD CONTROL VS/TW
COPY 2-OPERATING COMPONENT
COPY 3. OS/SRD
COPY 4-OC/DO/TFS
COPY 5 CCS-FILE
FORM 155 USE PREVIOUS EDI
4-77
A.
Selsty
CHIEF, OFFICIAL COVER BRANCH, CENTRAL COVER STAFFS
SECRET WN-SISM
E-2, IMPDET CL BY: 021964.
2181
(13-20-43)