JFK Assassination System ; Date: 10/1/201 Identification Form . Agency Information AGENCY :. HSCA RECORD NUMBER:  180-10073-10093 RECORD SERIES: NUMBERED FILES AGENCY FILENUMBER: 004876 Document Information ORIGINATOR: RUBY, SAMUEL FROM: RUBY, SAMUEL TO: TITLE: DATE: 01/24/1978 PAGES: 118 SUBJECTS : RUBY, SAM RUBY, JACK, BACKGROUND, ASSOCIATES AND RELATIVES DOCUMENT TYPE: OTHER TEXTUAL CLASSIFICATION : — Unclassified RESTRICTIONS: 3 CURRENT STATUS: —Redact DATE OF LASTREVIEW: — 10/25/1995 OPENING CRITERIA : COMMENTS : W/cover letter. Box #:102. v9.1 | NW S923 Doeold: 32245535 Page 1
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ea bs 4 ih Awe, a , Return for individ wh . | _ * Form. 6329 Retirement Savings Arrangement | "10768. 1" Bapartmantot tho Teasing (Under Sections 408 or 409 of the Internal. Revenue Code) Only This Side of Form is “ ;  Untornal Revenuo Service ce D> Attach to Form 1040.” a Open to Public Inspection’ "If you have established a retirement savings arrangement you must ¢ mplété- Part | and Part Il and ‘attach this form to your individual income tax return, Form 1040. In addition: (1) if you claim a deduction on your Form 1040 for contributions to your retirement savings arrangement, complete Part Ill; (2) if you have made contributions in excess of your allowable limitation for this year or prior years, complete Part IV; (3) if you are not yet age 5914 when you receive a diStribution from your retirement savings arrangement which is not due to a disability,.a- rollover contribution to another plan or retirement savings arrangement, or the transfer of an amount to a former spouise under a divorce-decree, you must complete Part V; (4) if you are 701% or older on the last day of the year, see: in- structions to determine if you are required to complete Part VI. _ . Name . . f If you are not required to file a Form 1040 check here Rar ttle Individual and Retirement Savings Information 1 Type of individual retirement savings arrangement: (a) [J Individual retirement account (b) [[] Individual retirement annuity (c) [] Individual retirement bonds 2 Were you during any part of the year an active participant in a qualified pensioll prof stock bonti: plan, including a qualified Keogh (HR 10) plan, or were you.covered under a sactio 403(b) annuit custodial account or under a government*retirement plan other than the Social Security ‘oF Railroad Reti i (Volunteer firemen and military reservists see specific instructions for line 2). \ If “‘Yes,"’ you are not allowed a deduction for your 1976 contributions to your indian étir Under penalties of perjury, | declare that | have examined this return, including ee ee knowledge and belief it is true, correct, and complete. If prepared by a person other than the taxpa of which the préparer has any knowledge. _» Preparer’s signature (other than taxpayer) Preparer’s identification number.’ Rate = ene AgiMile G gw Fem $329 re
Tr Your Social Security Number. . . .'. . . Biltsfiled by surviving spouse or beneficiary of an individual who created this retirement savings arrangement check here oO JFK Act 6 (3) f nd ‘enter name and social security number of individual for whom the arrangement was established B....... aneccccecnceee, _ “4 Indicate-your age as of the end of the year (If you checked item 3 do not complete this item): = (a) Under age-5914 ~(b) [] Age 59% to 7014 (c) [-] Over age 701% (if you check item?(c) complete Part VI below) 5B (a) If} during the year, you received a distribution of your entire account from a qualified pension, profit- sharing or stock bonus plan, because either (i) you terminated employment or (ii) your employer . terminated the plan, and you transferred (rolled over) such distribution to your arrangement, check here . . . 0 (b) If you checked (a) did you transfer the entire amount of the distribution (less any amounts you con- tributed to the qualified plan—see instructions) to your arrangement within 60 days of receipt of such distribution (or 12/31/76 if (a)(ii) applies and you received such distribution prior to 11/2/76)?. . . [] Yes [] No (c) If (b) was “Yes,"”’ complete lines (i) through (iii) below: Month j Day { Year (i) Date of transfer to. arrangement . 2... wk eee be be ek ew ew ew ew es ‘ { (ii) Date distribution was made to you from tie plan. wo. ke kk ke ke ke i i (iii) Name of trustee or insurance company to which the transfer was made (If bonds were purchased state “‘Bonds”) ...... (d)' (i) If within one taxable year, you received a distribution of your entire account from your employer's qualified pension, © 8 - ° “profit-sharing or stock bonus plan because the plan was terminated by your employer did you: (A) receive such amount on or after July 4, 1974 but prior to January 1, 1976, (B) transfer such amount, reduced Ly the amount of the income tax paid on the distribution on ° your 1974 or 1975 income tax return, to an arrangement and ~ (C) file a claim for refund of such tax paid? (Check “Yes” only if (A), (B) and (C) ALL apply.) . . [] Yes [ No a b? (ii) If (d)(i) is “Yes,” and you have received such refund or credit for such tax paid enter: - | Month? Day } Year ‘ (A) Date refund or credit received . 2 1 1 1 1 ee ee ee tt tt kt i ___ “ (B) Date refund or amount of credit was contributed to your retirement savings arrangement. . ' u Note: See Definition C in the Instructions concerning rollover contributions. 6 If, during the year, you transferred any funds from one retirement savings arrangement to another retire- | Month| Day | Year ment savings arrangement, enter the date of transfer here. . . . 1. 1. 2 ee ew wt te cg Caution: Such a transfer may be a taxable distribution. . . ; 7 If, during the tax year ‘covered by this form, you have entered into a prohibited transaction under section 4975 or borrowed any amount from your retirement savings arrangement or pledgéd any part of your arrangement as security for a loan, check here. fw we ww oO Note: See instructions for the tax consequences of such transactions. lzial..« Computation of Allowable Deduction  _ a oo (If you have entered into a prohibited transaction: under section 4975, do hot complete Part [Il or Part ‘ 'V for the retirement savings arrangement with which you entered into such prohibited transaction.) . 8 Wages, tips and other compensation from Form 1040 (ifa joint return do not include compensation of spouse) : (See definition B in the instructions for the meaning of compensation.). . . . . « 3 «© 8 © « « 9 15% of line 8 or $1,500, whichever is lesser (if you are 70? or over or answered “Yes” to line 2,enter zero). . 2 « «© e 10 Amount paid by you or on your behalf under all your retirement savings arrangements (do not include any amounts which were considered as “rollover contributions,” see lines 5 and 6, or the purchase price of any individual retirement bonds redeemed within 12 months of their date of purchase (see instructions) or life insurance portion of your endowment premium as reported on Form 5498 box 0) XN Vv 11 Allowable deduction, lesser of line 9 or line 10 (enter here and on Form 1040, line 40a) . . . . i Geindiy.=] Tax on Excess Contributions 12 Tax on excess contributions (see Part IV of the Specific Instructions if Part lil, line 10 exceeds line 11). Enter tax from worksheet here and on Form 1040, line 61 =. . 1. ww we ee ew le GEER /.=] Tax on Premature Distributions 13 Tax on premature distributions (see Part V of the Specific Instructions if you received a distribution from your retirement savings arrangement before you have attained age 5914). Enter tax from worksheet here and on Form 1040, line 57. 2. 1. 2 we ee ee : ew uz Tax on Undistributed Retirement Accounts and Annuities (See Instructions before completing this Part.) 14 Tax based on current year distribution method, see worksheet in Instructions . . . . . . ee ws 15 Tax based on aggregate distribution methods, see worksheet in Instructions . . . . 3; .. . oe 16 Tax due, lesser of line 14 or 15, enter here and on Form 1040, in your total for line 62. On the dotted line to the left of the line 62 entry space write ‘4974 tax,” and show the amount . ....: . ee i U.S, GOVERNMENT PRINTING OFFICE : 1976—O-218-176 EI. 13.2687299 ‘ 3
ue ie 7 : “s ; Department of the Treasury—Internal Revenue Service Tg 1040 U. S. Individual Income Tax Return — ~ | For Pf ivacy Act Notification, Occu- | Yours > »(2_¥ PAD : v3 ——__| pation | Spouse's > LT Single (Check only ONE box) 6a Regular (] Yourself [] Spouse pores checked p> 2 arried filing joint return (even if only one had income) b First names of your dependent children who y : _ 3-[f Married filing separately. If spouse is also filing give lived with you 2 " *~ spouse’s social security number in designated space above 2 Pre Ma Enter —} 2 ; a ; and enter full , 3 THOS number Bb ee a J .°> name here p> Ee c Number of other dependents (from line 7) . — YY, . =. . & O Unmarried Head of Household. See page 7 of instructions 3 d Total (add lines 6a,b, andc) . . . . + fosee ty > e Age 65 or older. [1] Yourself [7] Spouse Enter 5 [] Qualifying widow(er). with dependent child (Year Blind. . . . [] Yourself [] Spouse of5xes > spouse died > 19 ), See page 7 of Instructions. f TOTAL (add lines 6dande) .......©6 f . : 7 Other dependents: (b) Relationship (c). Months lived in your | (d) Did dependent | (e) Amount furnished for dependent’s support ~ bo . x . home. If born or died | have income of $750 “By YOU. If 100% | By OTHERS includ. (a) Name during year, write B or D. | or more? write ALL. ing dependent. $d SS 2 . gs Y : “ ” 8 Presidential Election Do you wish to designate $1 of your taxes for this fund? . _. |__| Yes_ Yi) No | poxtes) it'll ‘nat increase your -Campaign Fund . . If joint return, does your spouse wish to designate $1? . Yes Y\ No_| tax or reduce your refund. ° 9 Wages, salaries, tips, and other employee compensation (tach Forms B of Instructions.) rn i) —-p ~ | . . he i . 2 10a _ Dividends 16 of Instructions deseeeeeeeececcaeee teeeeee , 10b less exclusion ........0.0000022.0} eee , Balance f> |_10c]. o-= Pi (If gross dividends and other distributions are over $400, list in Part ! of Schedule B.) : . . t ; If $400 or less, enter total! without listing in Schedule B : = 11 ' Interest income. if over $400, enter total and list in Part Il of Schedule Bt “hrs 11 Ss. f GSE ; E E 12 Income other than wages, dividends, and interest (from line 37) 2... ew eee [22 _ | B] 13° Total (add lines 9, 10c, 1k and12). 2. 2... ee ee ee LB] PDO LZ ‘S| | 14 Adjustments to income (such as moving expense, etc. from line42) 2 6 2 we ek Ss = ee a 15a Subtract line 14 from line 13... woke ew ee we ee | 15 2a7Yyi 2 | 15b -O-- 2 b Disability income exclusion (sick pay) (attach Form 2440) coe ee 29) | Te 1? © ; c Adjusted gross income. Subtract line 15b from line 15a, then complete Part ti on back. , . i " 9 (If less than $8,000, see page 2 of Instructions on “Earned Income Credit."’") . . . . 4 15¢ ; wy] ? f i 0 : . -Tax'Table | Tax Rate Schedule X, Y or Z| Schedule D . : 16 Tax, check if from: F TO OoorTo oo ot Oo | -- : : 3 Schedule G Form 2555 | OR Form 4726 | 16 o- if b line 3 is checked z 17a Multiply $35.00 by the number of exemptions on line Gd . 17a i i page 10 of f istru sions) Enter 2% of line 47 but not more than $180 ($90 if box 3 is checked) 17b bas A7c_ 18 Balance. Subtract line 17c from line 16 and enter difference (but not less than zero) 19 Credits (from line 54) : coe 20 Balance. Subtract line 19 from line 18 and enter +r difference (but not less than zero) . 21 = = Other taxes (from line 62) 22 Total (addlines20and21). ......~. 23a Total Federal income tax withheld. GMtopm: ht : (include amount allowed 1976 estimated tax payments . as credit from 1975 return) - Earned income credit. of Instructions) , Amount paid with Form 4868 Other payments (from line 66) 24 TOTAL (add lines 23a through e) 25 Af line 22 is larger than line 24, enter BALANCE DUE IRS ‘(Check here [> [_]. if Form 2210 or Form 2210F is attached. See page 10 of instructions) | TT Tax, Payments and Credits eaog o on eg iy check or money order and S| Yj, ake, payable to > Internal Due or Refund 26 If line 24 is larger than line 22, enter amount OVERPAID: rns . 27 “Amount of line 26 tobe REFUNDED TO YOU . 2). 7 ip 27 Tendon Dal _ 28 — Amount of line 26 to be credited on 1977 estimated tax p> [ 28 | | WMMMM@q@qWVWJTTV@qMC@q}]Ho Under penalties o1 perjury, | declare that | have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based ‘on all information of which Preparer has any knowledge. * Please attach Check or Money Order here ~ Sign here | Your signatire : Date ID peeeeeee er eer Preparer’s signature (and employer's name, if any) SCS Sé@Dadtle “signature a. employer's name, if any) ~ Date Spouse's signature (if filing jointly, BOTH must sign even if only one had income) _|> Identifying Number (see instructions) y Address (and ZIP code) ae wt 218-052-2 CNW 55923 DocId:32245535 Page 5. . oe eh