Originator: CENTRAL INTELLIGENCE AGENCY
From: CIA
Document date: 00/00/0000
Document type: PAPER, TEXTUAL DOCUMENT

## Page 1

124-90146-10055

2023 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992

JFK Assassination System

Date:

Identification Form

5/27/201

Agency Information

AGENCY: FBI

RECORD NUMBER : 124-90146-10055

RECORD SERIES: HQ

AGENCY FILE NUMBER :

105-93072-31

Document Information

ORIGINATOR: CENTRAL INTELLIGENCE AGENCY

FROM:

CIA

TO :

TITLE :

DATE: 00/00/0000

'PAGES:

16

SUBJECTS :

HERMAN ROSCOE TALLEY

RICHARD THOMAS GIBSON

DOCUMENT TYPE: PAPER, TEXTUAL DOCUMENT

CLASSIFICATION: Secret

• RESTRICTIONS: 1A

CURRENT STATUS: Redact

DATE OF LAST REVIEW:

10/16/1998

OPENING CRITERIA: APPROVAL OF CIA

COMMENTS:

STATEMENT; ENCLOSURE, ENV

v9.1

HH 50953

DocId: 32339223

Page 1

12

---

## Page 2

CONOVC

SunsocioNg

12002

CHO

ourxca molatzara

NTada:

ataua Ucesur aios tot vocin auy

---

## Page 3

HISTORY GATEMENT

CIA HAS NO OBJECTION TO

DECLASSIFIGATION AND/OR,

RELEASE OF CIA INTOMMATION

V1r/e 5728/9

BOUNCHIAS SARMULE

ALL FBI INFORMATION CON

HEREIN IN UNCLASS.RIAD

DATE 10/14/194

_SYSPS MA

63912

tions for which your

have sufficient soom.

carefully, fllegible or incomplete forms will not receive consid.

DO YOU UNDERSTAND THE INSTRUCTIONS!

Meo Bai

5 4142

- NAME

Mrs

• HERMAN

PRESINT ADDRESS

Ducat

MY DISPELES GUERRE MO MINTENA

B. NiCKNAME

NONE

• WHAT OTHER NAVAS HAVE YOU USEDE MON E

NAMES? -

NONE

HOW LONE! MINE WALIN HANGS ENIPALAN MONE

BRITAERE

- BY MARRIACE? MUEL

BY NATURALZATION CRTIFICATE NO. _NA.

HAVE YOU HAD A PREVIOUS NATIOnALITY!

NA

5 OF NO)

DOLD BEVEN WHAT DATE ME TO NE ANY OT NAINA NO

GIVE PARTOULArS NONE

5987688 38-1

---

## Page 4

(2)

E. I BORN OUTSIDE U. 8. WHEN DID YOU FIRST ARRIVE IN THIS COUNTRY? BORN IN USA.

PORT OF ENTRTY _NA

_ ON PASSPORT OF WHAT COUNTRY!

NA

LAST U. S. VISA -

2. PHYSIOAL DESCRIPTION

ACE -

-36

TOO SIDES MALE

• 1MGH S39

- WHICHT 1TS

LEET FORB WEND

BIES BROWN HAD BLACK OUTION BROWM SONES LET 120015

BOULD MEAT

.. OTHER DISTINGUISHUNG FRATURIS MUSTACHE

SEO. 8. MARITAL STATUS

A SINGLE

• MARRIED MAIRRIEDDIVORODD NO

STATE DIE, PLACE, AND REASOS JOB ALL SPARATIONS, DIVO

* WIDOWED

B WIFE OR HUSBAND

(IF

YOU HAVE BEEN MARRIFD MORE THAN ONCE INGLUDING ANNUI

MENTS- USE A SEPARATE SHEET FOR FORMER WIPE OR HUSBAND CIVING

ITA REQUIRE

BELOW FOR ALL PREVIOUS MARRIACESD

ANS OF STOOLMNA

BEAD

PLACE AND DATE OF MARRIAGE

ROCKLE AR

LIVING OR DECEASED LIVING. DATE OF DECHASE

-CAUSE

SAW USMANDE

IF BOIN OUTSIDE U. & INDICATS DATE AND PLACE OF ENTRY NO

ONSHIP NA

WHERE?.

COUNTRY NISH

BIRANS OF ONE GOVE SINTER, & $ O8 FORBIEN

JEN 15 IRAQ

TO PRESENT US DEPT. OF AGRICULTURE

ARTHER & TABLED

B3

ROFP

A3 GATHERSBURG, MD.

(& WILBIRD W. TABBEY DOB. 0-B-25

RoF. D. #3 GAMHERSBURG MD

(a MAEL PETERSON DOB DOB2-B428

SEC. V

COEBSIE & GULESPIE D•OB D-129

DOI - YOU ST. NV tHI

(08) AGNES

B

MINOR DOB. 5-18-8%

ITE BORAIN ST OBERLIN, ONIO

(* UPTON & TALLEY

D.D. B. 02-1-34

RFD #3 GRITHERSBURG, MD

WILLEND W.TELLEY

(BRO) NErVE

REDA 3 GAUWERS BURG MO

RS. PUBUR MEALTH. BETESDI. MD.

JUDD

MINOR

WATTE HOUSE

MAE L. PETERSON (ReS. TALEY)

FEDERAL HOUSING. WASH. DOG.

SECT CONTINUED

ESTELLE MINOR

HGE 4&

1860 PEN. ST. NE

JILTON TABLE

329 CHURCH ST NU

RICHARDTABLEY HGE 59

BOG KENUB WORTH HUE NE

SADIE THOMBS MGE 38

HARE SISTERS END BROS.

SADIE MILLER

AGE 55

689 N 328Е. РНОВНОВВРНОЙ, РЕ.

---

## Page 5

70055)

F, TO YOUR KNOWLEDGE, ANY OF THE ABOVE HAS CONDUCTED AN INVESTICATION

U, INDICATE BELOW THE NAME OF THAT AGENCY AND THE APPROXIMATE DATE

THE INVESI

GATION:

(NA

INAVE A LOYALTY CLARENCE INTRE

LAGRICALTURE DEPT®

APRI

1948

SEC.

26. PERSON TO BE NOTHIN IN CASE OF EMERGENOYs

• RELATIONSHP WIE E

AN ON WISHMEN C

HEREIN WILL BE INVESTIGATED.

DISCOVERED

INVOLVED OR NOT, WHICH I

WHETHER YOU WERE DIRECTLY

NIGHT REQUIRE EXPLANATION? IF SO,

NO

248400 08800

See.

28. I CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE

RIST OF MY KNOWLIDGE AND BELIEF, AND I AGRIE THAT ANY MISSTATEMENT

OR OMISSION AS TO A MATERIAL

FACT WILL CONSTITUTE GROUNDS FOR IM-

MEDIATE DISMISSAL OR REJECTION OF MY APPLICATION.

SIGNED AT

USE THE FOLLOWING PAGUS FOR EXTRA DETAILS.

NUMBER ACCORDING TO THE NUM-

BER OF THE QUESTION TO WHICH THEY RELATE.

THE ADDED MATERIAL.

SAME SIZE AS TIF

IF ADDITIONAL SPACE IS REQUIRED USE EXTRA PAGES THE

BE AND SIGN EACH SUCH PAGE.

SEG. 4. CHILDREN OR DEPENDENTS (Include partial dependents)

1 SAN ERA KAMALL TRAY MANSON

OWNSHP YES

& MAN ELVER AUEL MLLEY MATIONSH SON

& NAVE TACQUELIN®

NONE

PARKS.

• ADDRESS LUL

FULL NAME

RIE MARD

MAURICE

LIVING OR DECRASID LIVING. DATE OF DEGRASE

TRAY

• CAUSE.

HIS O LAT ANIS MAS THINK WASK

• I BORN OUTSIDE U. &. INDICATE DATE AND FLACE OF ENTRY NO

CITWENSHIP -

= WHEN ACQUIREDE _NIN

• LAST EMPLOYER

EMPLOYER'S OR OWN BUSINESS ADDRESS

UTABY SUVICE FION NONE TO

- BRANCH OF SERVICE NE

COUNTRY -MR

NA

Sec. & MOTHER (Give the same tutormation for stepmother on a separate sheet)

PULL MANS LAURA

LIVING OR DEODASED LAVING DATE OF DECRASE

@AUSE

DATE OF BUSE I-TE I2. BLACE OF BRUI REDS BNUTHERSDURE MI

CHAINSHIP NE.

→ WHEN ACQUIREDE HE®

IF BORN OUTSIDE U. & INDICATE DATE AND PLACE OF INTRY NE:

---

## Page 6

(4)

OCCUPATION .

MILITARY SERVICE FROM NONE. 10

COUNTRY A

SEe. %. BROTHURS AND SISTERS (including half, step, and adopted brothers and sisters) &

1 DOLL DANE LANDERSON

VALLEY

PRISINT ADDISS LOS MISTONE

ALMINGE

"(Country"

, ABNOS

& PULL NAME CLIFTON

"(Country"

& DULL MAN MAURICE

SEe. 8. FATHER-IN-LAW

BELL

LIVING OR DEODASED LIVINE. DATE OF DECRASE

- CAUSE

SIN CLAWS ROCHUER

DATE OF BIH 1D2-85. PLACE OF BUI SENE MARIEND

I BORN OUISIDE & & IIICATE DATE AND PLACE OF INIRT MIH

CHIANSIT NATIVE WHIN ACQUITE MR.

CANNON RUNS A SMALL TOO

DATES OF MEMBERSHIP!

Name and Chapte

DATES OF MUMBERSHIP! «

Sb and Number)

- (Name and Chupter)

DATES OF MEMBERSHIPs.

To coma insand aba

DATES OF MEMBERSHIP:

See.

25. MISCELLANEOUS

A DO YOU ADVOCATE

(St. and Number

(St, and Number)

ERNMENT IN THE UNITED STATES?

(Stato)*

(State*

& DO YOU USE, OR HAVE YOU USED, INTOXICANES! LES

BASTINTO AMAS TIME

(SIRENT)

& MAVE YOU EVER BRUN ARRESEED, INDICED OE CONVICHED

AW OTHER THAN A MINOR TRAFFIC VIOLATION!

NAME OF

SLATE, COUNTRY, NATURE OF OFFENSE AND DISPOSITION OF CASE

NO

• IF SO. TO WHAT

. HAVE YOU EVER BEEN COURT-MARTIALID WHILE A MUMBER OF THE ARMED FORCES:

P ANSWER IS "YAS," GIVE DETAILS BELOW

ELIST BELOW

WHICH YOU HAVE APPLIDD FOR EMPLOYMINT SINCE 19408

DALY US DEPARTMENT OF AERICUSTORE

20-8443507

---

## Page 7

(100

LAWYER, CRA, ETC:

IF YES, INDICATE KIND OF LICENSE AND STATE NA

SUCH AS:

(1)

(2Đ

YOUR PATENTS OR INVENTIONS

(8)

PUBLIC SPEAKING AND PUBLIC RELATIONS EXPERIENGE

(AD HONORS AND FELLOWSHIPS RECEIVED

MONE

HAVE YOU A PHYSICAL HANDICA

INSIDERED IN ASSIGNING YOU TO WORI

EL.DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATUS OR DISTRICT

won Muntrary on Nwan

YES THAVE A POL DISABLY FROM THE ARMY

THE SERVICE THE ARMY LEGRAVAND TIMS INIURY.

SO. IA. ACTIVE U. S. OR FOREIGN MILITARY SERVICE

Vesad

aRMY

SEC.

REMARKS, NOME

8I8LIB0IVR SIBEVIOR BOATED AUDIER UN NONE

UNICATE NUMBSIP I MLIARY RISHVI ORGANZATONS MONE

15. CHRONOLOGICAL HISTORY OF EMPLOYMINT FOR PAST 15 YEARS.

FOR ALL PERIODS.

INCLUDE CASUAL EMPLOYMENT.

of

UNEMPLOYMENT®

PERIODS

LIST LAST POSITION FIRST.

ployment by a foreign government, regardless of dates.)

ON TRIAN PRESENT ASIAGSS

an anna rage man

HILE OF SOR LIDM DEFICIER

REASONS FOR LEAVING .....

---

## Page 8

(81)

EMPLOYING FIRM OR AGINEY CENTRAL SUPPLLSAGMON IS DINALAGRE

Countes

014-00

TO OF LUSINESS GOTTA REEL OF SUPRVISOR SAME & GARDINER

- SALARY &

-PER.

REASONS FOR LEAVING TRANSFERRED. TO HIGMEN LOB

TRON 215-30 10 L-M WILMA SION FOREMAN

2000.

AMES REALISE MD

RIND OF BUSINESS FARM

→ NAME OF SUPREVISOR I WAS MYONO

TILL OF JOB LOREMAN SELE SALARY S 540 PER HNNUAL

FROM C

EMPLOYING FIRM OR AGENCY

ADDRESS DE

(St and Numbs)

KIND OF BUSINESS.

TITLE OF JOB-

YOUR DUTIES

TORAWER GOU RAMENT SERI

- STATIN SEND

(city)

(Sinte)

NAME OF SUPPRVISOR -

County!)

• SALARY &..

•PER.

REASONS FOr LEAViNG

16: HAVE YA* EVIR BEEN DISCHARGED OR ASKED I

TION?

E YOU LEFT

DESIRE TO EXPLAIN? CIVE DETAILS:

NO

SEO 17. GENERAL QUALIMICATIONS

LANGUACT FRENCH sPRAs

LANGUAGE

= SPRAR

LANGUAGE

BOWLING

- READ SLIGHT WRE.

_ READ.

- READ -

= WRITE

_ WRITE -

AVEO

- 105

. HAVE YO

AS A RESULT OF TRAINING OR DXPERIENCE, WEICH

SINCE T-P9-CAL TO PRESEST AS I PERSONNEL FIDE CHERR

I HAVE MANLED CONDEMNS AND SIHEE MAURIAL FOR. •

THE FOREST SERVICE

OPERATION OF

NONE

APPROXMATE NONBER OF WORDS PER MINUTE IN TYPING 125).. SHORIAD.

---

## Page 9

(6)

SEC. 12. POSITION DATA

A. KIND OF POSITION APPLIED FOR ...

& IF YOU ARE WILLING TO TRAVEL, SPECIFY: OCCASIONALLY

PREQUINTLY

→ CONSTANTLY

ANYWEDRE IN THE UNID STATES NO. OUTSIDE THE UNITED STATES NO

EAST AND WESI

SEO. 18. EDUCATION.

DATDS ATTENDID 1922-

WICH SCHOOL 192 8

_ GRADUATE 19 28

_ GRADUATER 1932

COLLEGE

MONE

- As da

MAJOR AND SPORALTY - NONE

DATES ATTENDED - NA

COLLIET NA

MAJOR AND SPEGALTY NA

DATES ATTENDED Ni

CHIFF UNDERGRADUATE COLLEGE SUBJECTS.

-AR

_ YEARS COMPLEMED NE

_ DEGRE NA

• BARS COMPILIND NA

_ DUERE NA

CHILT GRADUATE COLLECT SUBIOTS MR

SEC.

MATELY-

-(Give residence and business addresses where possibles)

& SETH JACKSON

& ERWING WIGNER BUS ADDISESSIN

So DEPO OF AG

• ENNA GREER

BON ADDICTLY ANAL WAN

& COLMELLE BER SS AND CIA

WASHa

Sho

and business addres

ses were posslole.)

& REGIMILD PURVEIR BUS ADD

City

Jus. AyJ..

BOB MYRIE GENE WASN

& WELTER PACE

ADD THE PENTAGON

_WASH®

ES. ADD. EY2L DURSTAR WASY

MOUSING AUTHORITY

& WALTER WASHINGTON BUS ADDANTONAL CAPIOL

JIDH BLOYD

BOSDEPTOPAGRI

BUS. ADD. LIARS SID. WASHA

SEC.

20.

(Give residence and business addresses where possible.)

H ROBINSON

BUS. ADD.

AR MANASON

-WASHes

RES. ADD. 329 D. SISUWASH

& MELVINL FEGEANS

BUS, ADD. METRO POLMAN POLICE. WASN

& LOSER HUTCHINSON

RES. ADD. -

TESS WASH..

RES. ADD. I&21 MALE SESH. WASH

21. FINANCIAL BACKGROUND

A. ARE YOU ENTIRELY?

OF OTHER INCOME AQN 3

DEPENDENT ON YOUR SALARY? YES. I NOT, STATE SOURODS

& NANDS AND ADDRESSES OF BANS WH WHOH YOU HAVE ACCOUNTS - NMI

(41)

---

## Page 10

90146-10055

(12)

& HAVE SOU HAN THAN I ON THEN DON LANUN NO

GIVE PARTICULARS, INCLUDING COURT!

D. GIVE THIRDE CREDIT REPERINCES-IN THE U. &

I NAME

EURNATURE

ADDRESS

& NAME BELLCLOTHING

ADDRESS

& NAME ABRA CRADIUNON

ADDRESS

SENL

DESH

SEC.

22. RESIDENCES FOR THE PAST 15 YEARS

FROM GE 18-12 10 Prosent

WASHe DC

DON STAM TAIR LIT GI

FrOM

- 1r0

(S, and number

(Chys

"(Sinte)

FROM

(Country)

TROM

- 110

(St end number).

(State)

"Country"

= 10 00000

(St and number.)

"(State)

Country!

• 20 000000

S, and number cly)

"(Sine)

FROM

- 110.

(city)

SoO.

23. RESIDENCE OR TRAVEL OUTSIDE OF THE UNITED STATES

A. FROM NONE 10-

NA

•city a section)

FroM

... TO -

FROM :.

→ 70 -

FROM

- 10.

City a Beatin)

Mountry"

(Countes

CombeD

(Counts)

FROM

SEC.

24.

CLUBS, SOCIETIES, AND OTHER ORGAN ATIONS

JUST NAMOUS

AINID

ADDRESSES

OF ALL CLUBS

PLOYEE GROUPS, ORGANIZATIONS OF ANY

SOCIETIES, PROPESSIONAL SOCIETIES

KIND

DATES OF SMASHIP YEARS RENEWAL SINCE 1945

DATES OF MEMBERSHIP 1947 TO PRESENT

8 a

(St. And Numbers

DATES &

@MRERSHIP:

SEC. 9. MOTHER-IN-LAW

LIVING OR DOORASED LIVING. DATE OF DIcTAsE

DATE OF BIRTH

- PLACE OF BIRTY SENESE MARYANAD

IT BORN OUISIDE U. & INDICATE DATE AND PLACE OF ENTRY N.F

OCCUPATION DOMESTIC.

- LAST EMPLOYDE DALYS WORK

OR WHO ARE NOT CITIAINS OF THE UNITED STATES:

1 NAM MONE

- DLATIONSHIP NA

OH VANSHP NA

ADDRESS

& NAME CLONE

NA

RELATIONSHIP -

, AGE

Contes

• AGE.

& NAME MONE

(city)

- RELATIONSHIP -NA

• AGE.

(ory)

"(Sinto)

SEC. 11. RILATIVES BY BLOOD OR MARRIAGE IN THE MILITARY OR CIVIL SERVICE OF

THIS U. S. OR OF A FOREIGN COVERNMINT:

& 8AM TAMES

TYPE AND LOGATION OF SERVICE IT KNOWN CEMBRAL ASCOUNTING OFFREE DE.

2 NAME ANNA A LEWIS

= RELATIONSHIP SISTER. ACE

CIHZENSHIP NHILE

TYPE AND LOCATION OF SERVICE I KNOWAD GENRRAL ARCOUATINE ORACE DE.

8 ME SPARSON MAYAN

- ADORESS TO HIM N

TIE AND LOC YOU O SIC LOW LEDERAL HOUSING

10-02858-0

---