## Page 1

Heleased under the John F. Kennedy

Assassination Records Collection Act of

1992 (44 USC 2107 Note]. Case#:NW

BA513 Date: 09-16-2025

Date

Page

:

08/18/98°

1

AGENCY

RECORD NUMBER

RECORDS SERIES

AGENCY FILE NUMBER

JFK ASSASSINATION SYSTEM

IDENTIFICATION FORM

AGENCY INFORMATION

: INSCOM/CSF

: 194-10005-10140

: DOD AFFILIATED PERSONNEL AND INCIDENT INVESTIGATIONS

: PAGES

1110-1117

DOCUMENT INFORMATION

ORIGINATOR : USA

FROM

TO

TITLE

: STATEMENT OF PERSONAL HISTORY

DATE

: 10/05/66

PAGES

: 8

SUBJECTS : SCHEER, ROBERT

DOCUMENT TYPE : PAPER,

TEXTUAL DOCUMENT

CLASSIFICATION: UNCLASSIFIED

RESTRICTIONS : 3

CURRENT STATUS : RELEASED WITH DELETIONS

DATE OF LAST REVIEW : 03/07/95

OPENING CRITERIA :

COMMENTS :

NW 83613 Docld:34530159 Page 1

---

## Page 2

ARMED FORCES SECURITY QUESTIONNAIRE

I.- EXPLANATION

1. The interests of Nacional Security require that all persons

compelled to furnish any statements which you may reasonably

being considered for membership or rerention in the Armed

believe may lead to your prosecution for a crime.

This is the

Forces be reliable, trustworthy, of good character, and of com-

only reason for which you may avail yourself of the privilege af-

plete and unswerving loyalty to the United States.

forded by the Fifth Amendment in refusing to answer questions

it is necessary for you to furnish information concerning your

under Part IV below. Claiming the Fifth Amendment will not

The answers which you give will be used

by itself constitute sufficient grounds to exempt you from mili-

in determining whether you are eligible for membership in the

tary service for reasons of security.

You are not required to

Armed Forces, in selection of your duty assignment, and for such

answer any questions in this questionnaire, the answer to which

other action as may be appropriate.

might be incriminating. If you do claim the privilege granted by

2. You are advised that in accordance with the Fifth Amend.

the Fifth Amendment in refusing to answer any question, you

ment of the Constitution of the United

should make a statement to that effect after the question involved.

II.— ORGANIZATIONS OF SECURITY SIGNIFICANCE

1. There is ser forth below a list of names of organizations,

Armed Forces. Your age at the time of such association, cir-

groups, and movements, reported by the Attorney General of the

cumstances prompting it, and the extent and frequency of

United States as having significance in connection with che

involvement, are all highly pertinent, and will be fully weighed

National Security. Please examine the list carefully, and nore those

Ser forth all such factors under "'Remarks" below, and continue

organizations, and organizations of similar names, with which you

on separate attached sheets of paper if necessary.

are familiar. Then answer the questions set forth in Part IV below.

3. If there is any doubt in your mind as to whether your name

2. Your statement concerning membership or other association

has been linked with one of the organizations named,

with one or more of the organizations named may nor, of itself,

whether a particular association is "worth mentioning," make a

cause you to be ineligible for acceptance or retention in the

full explanation under "Remarks."

Organizations designated by the Attornay Gonoral, pursuant to Executive Ordor 10450, aro listed balow:

Communist Party, U. S. A., its subdivisions, sub. American Slav Congress.

sidiaries and affiliates.

Commitree for a Democratic Far Eastern Policy.

Committee for. Constitutional and Political Freedom.

Communist

Political

Association.

its subdivisions,

American Youth Congress.

Commitree for the Defense of the Pitsburgh Six.

subsidiaries and affiliates, including-

American Youth for Democracy.

Committee for Nationalise Action.

Alabama People's Educational Association.

Armenian Progressive League of America.

Committee for che Negro in the Arts.

Florida Press and Educational League.

Associated Klans of America.

Committee for Peace and Brotherhood Festival in

Oklahoma League for Political Education.

Association of Georgia Klans.

Philadelphia.

People's Educational and Press Association of Texas.

Association of German Nationals / Reichsdeutsche

Commitree for the Protection of the Bill of Rights.

Virginia League for People's Education.

Committee for World Youth Friendship and Cul-

Young Communist League.

Ausland-Organization der NSDAP, Overseas Branch

tural Exchange.

of Nazi Party.

Committee to Defend Marie Richardson.

Abraham Lincoln Brigade.

Committee to Uphold the Bill of Righes.

Abraham Lincoln School, Chicago, Illinois.

Action Committee to Free Spain Now.

Benjamin Davis Freedom Committee.

Commonwealth College, Mena, Arkansas.

American Association for Reconstruction in Yugo-

Black Dragon Society.

Congress Against Discrimination.

Boston School for Marxist Studies, Boston, Massa-

Congress of the Unemployed.

Connecticur Committee to Aid Victims of she Smith

American Branch of the Federation of Greck Mari-

Act.

time Unions.

Bridges-Robertson-Schmidt Defense Committee

American Christian Nationalise Party.

Julgarian American People's League of the United

Connecticut Scate Youth Conference.

Congress of American Revolutionary Writers.

American Committee for European Workers' Relief

Congress of American Women.

American Committee for Procection of Foreign Born.

California Emergency Defense Committee.

Council on African Affairs.

American Committee for the Settlement of Jews in

Birobidjan, Inc.

California Labor School, Inc., 321 Divisadero Street.

Council of Greek Americans.

American Committee for Spanish Freedom.

Council for Jobs, Relief, and Housing.

Carpatho-Russian People's Society.

Council for Pan-American Democracy.

American Committee for Yugoslav Relief, Inc.

Central Council of American

Women of Croatian

Croatian Benevolent Fraternity.

American Commitree to Survey Labor Conditions in

Descent (also knoun as Central Council of Amer.

Europe

Dai Nippon Butoku Kai (Military Virtue Sociery of

American Council for a Democratic Greece, formerly

Japan or Military Ars Sociery of Japan).

known as the Greek American Council; Greek

Central Japanese Association (Beikoku Chuo Nippon.

Daily Worker Press Club.

American Committee for National Unity.

American Council on Soviet Relations.

American Croatian Congress.

Central Japanese Association of Southem California.. Dennis Defense Committee.

Dante Alighieri Society + Betueen 1935 and 1940).

American Jewish Labor Council.

Central Organization of the German-American Na-

Detroit Youth Assembly.

American League Against War and Fascism.

tional Alliance (Deutsche-Amerikanische Einbeits-

American League for Peace and Democracy.

Elsinore Progressive League.

American National Labor Party.

China Welfare Appeal, Inc.

Emergency Conference to Save Spanish Refugees

American National Socialist League.

I founding body of the Norsh American Spanish Aid

Chopin Cultural Center.

American National Socialist Party.

Citizens Committee to Free Earl Browder.

American

Nationalist Party.

Everybody's Committee to Outlaw War.

Citizens Committee for Harry Bridges.

American Patriots, Inc.

American Peace Crusade.

Citizens Committee of the Upper West Side (New

Families of the Baltimore Smith Act Victims.

American Peace Mobilization.

Families of the Smith Act Victims.

American Poles for Peace.

Citizens Emergency Defense Conference:

Federation of Italian. War Veterans in the U.S. A..

Citizens Protective League.

American Polish Labor Council.

Inc. (Associazione Nazionale Combassenti Italiani,

Civil Liberties Sponsoring Committee of Pittsburgh.

American Polish League.

Federazione degli Stati Uniti d' America).

Civil Rights Congress and its affiliated organiza. Finnish-American Mutual Aid Society.

American Rescue Ship Mission la projecs of the

tions, including Civil Rights Congress for Texas.

Florida Press and Educational League.

Unised Arnerican Spanish Aid Committee).

Veterans Against Discrimination of Civil Rights

American-Russian Fraternal Sociery.

Frederick Douglass Educational Center.

Congress of New York.

Freedom Stage, Inc.

American-Russian Instirute,

New York (also known

Friends of the New Germany / Freunde des Neuen

as the American Russian. Institure for Cultural Re-

Comice Coordinador Pro Republica Espanola.

lations with she Sovies Union).

Friends of the Sovier Union.

American Russian Institute, Philadelphia.

Committee to Abolish Discrimination in Maryland.

American Russian institute of San Francisco.

Commitree to Aid the Fighting South.

American Russian Institute of Southern California.

George Washington Carver School. New York Ciry.

Committee to Defend the Rights and Freedom of

German-American Bund ( Amerikadeusscher Volks.

Los Angeles.

Pittsburgh's Political. Prisoners.

FORM 98

PREVIOUS EDITIONS OF THIS

NW 88615 Bocld:34530159 Page 2

RE OBSOLETE (for Army use).

Page !

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## Page 3

German American Republican League.

German American Vocational League 1 Deussele

Amerikunische Berufsge-inesnselufs)

Guardian Club.

Harlem Trade Union Council.

Hawar Croil Liberties Commitree.

Heimuska Kai. also known as Nokuber Hereki.

Gimusha Kas. Zaibel Nihonjin.

Hervaku Gimu.

sha Kar and Zaiber Heimusha Kai (Japanese Re.

sidine in Menetica Milliary Conscripis AssOrIulIOn).

Hellen American Brotherhood.

Hinode Kai ‹ Impersal Japanese Reservists)

Hinomaru

Kal (Rising Sun Flag Sorely -a proup

of Japanese Wur l'elerans)

Hokuber Zago Shoke Dan r Narch Ameriion Resene

Omiers. 151041411011)

Hollywood Writers Mobilization for Defense.

Hungarian Amerian Council for Democracy.

Hungarian Brotherhond.

Idaho Pension Union.

Independens Party (Seattle. Washingion).

Independent People's Party.

Industrial Workers of the World.

International Labor Defense.

International Workers Order, its subdivisions, sub.

sidiaries and affiliates.

apanese Association of America

apanese Overseas Central Society I Killul Doh

Chuo Kur)

Japanese Overseas Convention, Tokyo. Japan, 1940.

Japanese Protective Association / Recruiting Organ.

12d110n)

Jefferson School of Social Science. New York Ciry.

Jewish Culture Sociery.

Jewish Perple's Committee.

Jewish People's Fraternal Order.

Jikyoku Lin Kai (The Commultee for she Crises).

Johnson-Forest Group.

Johnsonites.

Joins Antr-Fascist Refugee Commitree.

Joint Council of Progressive Italian-Americans, Inc.

Joseph

Weydemeyer School of Social Science, Sr.

Louis. Missouri.

Kiber Seinen Kal 1 Assocration of U.S. Cilizens of

jupanese aniestry lion have resurned to America alter

sincling in Jup.en)

Knights of the

Whice Camelia.

Ku Klux Klan.

Kyfhaeuser, also known as Kyffhacuser League

(Kylfhseuser Bund). Kyffharuser Fellowship (Kyff.

hauser Kumeradschafts

Kyffhaeuser War Relief (Kyffharuser Kriegshelfsuerk).

Latur Council for Negro Rights.

Labor Research Association, Inc.

Labor Youth League.

League for Common Sense.

League of American Writers.

Lictor Sociery (liulian Black Shirts).

Macedonian-American People's League.

Mario Morgantini Circle.

Maritime Labor Commitice to Defend Al Lannon.

Maryland Congress Against Discrimination.

Massachusetts Commitree for the Bill of Righes.

Massachusetts Minute Women for Peace (nor con

lected with the Minute Women of the U.S. A.

Maurice Braverman Defense Commitee.

Michigan Civil Righis Federation.

FOLD HERE

Michigan Council for Peace.

Michigan School of Social Science.

Nanka Teikoku Gunyudan / Imperial Military Friends

Group or Sourhern California

National Association of Mexican Americans (also

known as Asociaiion Nacional Mexico-Americano).

National Blue Star Mothers of America (not to be

confused with the Blue Star Mothers of America

organized in February 1942).

National Committee for the Defense of Political

National Committee for Freedom of the Press.

National Committee to Win Amnesty for Smich

National Committee to Win the Peace.

National Conference on American Policy in China

and che Far East (a Conference culled by ibe Com-

missee for a Demniralid Far Easier Policy).

National Council of Americans of Croacian Descent.

Narional Council of American-Sovier Friendship.

National Federation for Constitutional Liberties.

National Labor Conference for Peace.

National Negro Congress.

National Negro Labor Council.

Nationalist Party of Puerto Rico.

Nature Friends of America (Since 1935)

Negro Labor Victory Committee.

Nichiber Kogyo Kaisha / The Greus Fujis Theurre).

North American Commince to Aid Spanish Democracy

North American Spanish Aid Commirtee.

Northwest Japanese Association.

Ohio School of Social Sciences.

Oklahoma Commirtet to Defend Political Prisoners.

Oklahoma League for Political Educarion.

Original Souchern Klans, Incorporated.

Pacifir Norchwest Labor School. Scattle. Wasting.

Palo Alto Peace Club.

Parrido

del Pueblo of Panama (operating in she

Canul Zone).

Peace Information Center.

Peace Movement of Ethiopia.

People's Educational and Press Association of Texas.

People's Educational Associarion (Incorporated under

name Los Angeles Educational Association, Ins ).

also known as People's Educational Center. Peo-

ple's University,

People's Institute of Applied Religion.

Peoples Programs /Seasile, Washingion).

People's Radio Foundacion.

People's Rights Party.

Philadelphia Labor Commitree for Negro Righes.

Philadelphia School of Social Science and Ar.

Photo League (New York Cliv).

Pitrsburgh

Arts Club.

Political Prisoners' Welfare Committee.

Polonia Sociery of the IWO.

Progressive German-Americans, also known as Pro.

gressive German-Americans of Chicago.

Proletarian Party of America

rorestant War Vererans of the United States. In

Provisional Committee of Citizens for Peace, South.

west Area.

Provisional Committee on Latin American Affairs.

Provisional Commirice to Abolish Discrimination

in the Stare of Maryland.

Prierto Rican Comite Pro Libertades Civiles (CLC).

attorriquenos Unidos (Puerto Ricans United).

Quad City Committee for Peace.

Queensbridge Tenants League.

Revolurionary Workers League.

Romanian-American Fraternal Sociery.

Russian American Sociery, Inc.

Sakura Kai (Pasriosir Sociesy. or Cherry Associaion.

composed of velerans of Russo-Japanese War).

Samuel Adams School, Boston, Mass.

Santa Barbara Peace Forum.

Schappes Defense Committee.

Schneiderman-Darcy Defense Committee.

School of Jewish Srudies, New York Ciry.

Seattle Labor School, Seattle, Washingson.

Serbian - American Fraternal Sociery.

Serbian Vidovdan Council.

Shinso Temples (Limited to Stare Shinto abolished

in 1945).

Silver Shirt Legion of America.

Slavic Council of Southern California.

Slovak Workers Sociery..

Slovenian-American National Council

socialist Workers Party, including American Com.

mittee for European Workers Relief

Sokoku Kai ‹ Fasherlund Sorrery)

Southern Negro Youth Congress.

Suiko Sha r Reserre Officers Assocratson, Los Angeles).

Syracuse Women for Peace.

Tom Paine School of Social Science, Philadelphia,

Pennsylvania.

Tom Paine School of Westchester, New York.

Trade Union Committee for Peace.

Trade Unionists for Peace.

Tri-Stare Negro Trade Union Council.

Ukranian• American Frarernal Union.

Union of American Croatians.

Union of New York Veterans.

United American Spanish Aid Commitree.

Unired Commitree of Jewish Societies and Lands.

manschaft Federations, also known as Coordina.

cion Committee of Jewish Landsmanschaften and

Fraternal Organizations.

United Committee of South Slavic Americans.

United Defense Council of Southern California.

United Harlem Tenants and Consumers Organiza.

rion.

United May Dav Committee

United Negro and Allied Vererans of America.

Vererans Against Discrimination of Civil Rights

Congress of New York.

Vererans of the Abraham Lincoln Brigade.

Virginia League for People's Education.

Voice of Freedom Committee

Wale Whuman School of Social Suence. Newark

New Jersey

Washington Bookshop Association.

Washington Committee 1o Defend she Bill of Rights

Washingron Committee for Democratic Action.

Washington Commonwealth Federation.

Washington Pension Union

Wisconsin Conference on Social Legislation.

Workers Alliance I sime 4prs/ 19101

Yiddisher Kulcur Farband

Yugoslav-American Cooperative Home. Inc.

Yugoslav Seamen's Club, Inc..

III. —INSTRUCTIONS

1. Set forth

an explanation for each answer checked "Yes"

U. S. C., Section 1001. You are advised, however, that you

under question 2 below under "Remarks."

Attach as many

will not incur such liability unless you supply inaccurate state-

extra sheets as necessary for a full explanation, signing or initial.

with knowledge of their untruthfulness. You are there-

ing each extra sheet.

fore advised that before you sign this form and turn it in to

2. Title 18, U. S. Code, Section 1001, provides, in pertinent

Selective Service or military authorities, you should be sure that

"Whoever

falsifies, conceals or covers up ... a ma-

it is truthful; that detailed explanations are given for each "Yes"

cerial fact, or makes any false . . . statements

or makes

answer under question 2 of Part IV below, and chat details given

or uses any false writing . .

shall be fined not more than

are as full and complete as you can make them.

$10,000 or imprisoned not more than s years, of both."

Any

3. In stating details, it is permissible, if your memory is hazy

false, fraudulent or fictitious response to the questions under Part

on particular points, to use such expressions as. "I think," "in

IV below may give rise to criminal liability under Ticle 18,

my opinion," "I believe." or "to the best of my recollection."

2

3

Page 2

NW 88613-DöEld:34530159 Page 3

US GOVERNMENT PRINTING OFFICE. 19610 - 607912

For Official Use Onlv

Page d

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## Page 4

1. I have read the list of names of argonizations, groups, and more-

menis set forth under Part Il of this form and the explanation which

precedes it.

2. Concerning the list of organizalions, groups and morements set forth

under Part I1 above:

a. Are you now a member of any of the organizations, groups, or

movements listed?

b. Have you ever been a member of any of the organizations, groups,

or movements listed?

6. Are you now employed by any of the organizations, groups, or

movements listed?

d Have you ever been employed by any of the orgonizations,

groups, or movements listed?

e. Have you ever attended any meeting of ony of the organizations,

groups, or movements listed?

1. Have you ever attended ony social i athering of any of the organ.

izations, groups, or movements listed?

g. Have you ever attended any gothering of any kind sponsored by

any of the organizations, groups, or movements listed?

h. Have you prepared material for publication by any of the organ.

izations, groups, or movements listed?

i. Have you ever corresponded with any of the orgonizations, groups,

or movements listed or with any publication thereof?

REMARKS

IV.-QUESTIONS

(For each answer checked "Yes" under question 2, set forth o full explanation under '"Remarks" below)

YES

NO

YES

1. Have you ever contribuled money to any of the organizations,

groups, or morements listed?

Have you ever contributed services to any of the organizations

roups, or movements listed

Have you ever subscribed to any publication of any of the org

stions, groups, or movements liste

.. Havey ou ever been employed by a foreign government or any

1 Are you now a member of the Communist Party of any foreign

country?

0. Have you ever been a meniber of the Communist Party of any

foreign country?

p. Have you ever been the subiect of a loyalty or security heoring?

YES NO

9. Are you now or have you ever been a member of any organiza.

tion, association, movement, group or combination of persons

not on the Attorney General's list which odvocates the overthrow

of our constitutional form of government, or which has adopted

the policy of advocating or approving the commission of acts of

force or violence to deny other persons their rights under the

Constitution of the United States, or which seeks to alter the form

of government of the United States by unconstitutional means?

r. Hare you ever been known by any other last name than that used

in signing this questionnaire?

I refuse to answer these question,

beruse they vikte any rights greated

to mme waver the fiost, Fitth,

and

Fourteenth Amendoment te the

M.s.

Constitutin.

"liJ

Page 3

+

REMARKS (Continued)

NW 88613 Docld:34530159 Page 4

---

## Page 5

REMARKS (Continued)

Robert Scheer, born 4 April 1936 in Bronx, New York,

a regiatrant under the Universal Military Training

Act, was this date given an opportunity to execute

DD Form 98 and in my presence he refused to do ao.

YRON K. HAYASHID

I/LT, AGC

--,.

CERTIFICATION

and have obtained a complete explanation

lave brained complet thinesion i erie chit he statements made by questine Part he meane and on an supple

mental pages herero attached, are full, true, and correct.

TYPED FULL NAME OF PERSON MAKING CERTIFICATION

SERVICE NUMBER (If any)

SIGNATURE OF PERSON MAKING CERTIFICATION

TYPED NAME OF WITNESS

DATE

SIGNATURE OF WITNESS

NW 88615- BioE/d:34530159 Page 5

1113

US GOVERNMENT PRINTING OFFICE: 19610 - 607912

For Official Use Only

Page 4

---

## Page 6

STATEMENT

UNAL HISTORY

INSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all

answers.

All questions and statements must be completed.

If the answer is "None," so state.

Do not misstate or omit material

fact since the statements made herein are subject to verification.

If more space is needed, use the Remarks section, item 20, and

attach additional sheets if necessary. The information entered hereon is for official use only and will be maintained in confidence.

Print) FIRST NAME-MIDDLE NAME--MAIDEN NAME (If any) - LAST NAME

• MRS.

• MISS

ROBERT (NMN) SCHEER

STATUS

CIVILIAN

MILITARY ON ACTIVE DUTY

3. ALIAS(ES). NICKNAME(S). OR CHANGES IN NAME (Other than by marriage)

• None

5. DATE OF BIRTH (Day

month, year)

4 April 1936

4. PERMANENT MAILING ADDRESS

2828 Milvia

St.,

Berkeley, California

PLACE OF BIRTH (City. County, State, and Country)

PLACE CERTIFICATE RECCRDED

Bronx, New York, New York, USA

Bronx, New York

RACE

HEIGHT

WEIGHT

COLOR OF EYES

COLOR OF HAIR

SCARS. PHYSICAL DEFECTS. DISTINGUISHING MARKS

Cauc

70"

180

Brown

Brown

None

6. DO YOU HAVE A HISTORY OF MENTAL OR NERVOUS DISORDERS? • YES &*NO

ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS

NARCOTICS OR BARBITURATES? • YES

IS NO

ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES?

ANSWER TO ANY OF THE ABOVE IS "YES."' EXPLAIN IN ITEM 20.

WYES SNO

IF THE

7. U.S.

NATIVE

IF NATURALIZED, CERTIFICATE NO:

IF DERIVED. PARENTS' CERTIFICATE NO(S).

CITIZEN

DATE. PLACE. AND COURT

ALIEN

Olef

NO

[ROe

REGISTRATION NON'T I F. NATIVE COUNTRI

"I DATEAND PORT OF ENTRY

DO YOU INTEND TO BECOME

A U. S. CITIZEN?

YES

NO

MILITARY SERVICE

ARE YOU PRESENTLY ON ACTIVE DUTY IN THE U.S. ARMED FORCES DRAWING FULL PAY? YES X NO IF "YES." COMPLETE THE FOLLOWING:

GRADE AND SERVICE NO:

SERVICE AND COMPONENT

ORGANIZATION AND STATICN

DATE CURRENT ACTIVE

SERVICE STARTED

ARE YOU PRESENTLY A MEMBER OF A U.S. RESERVE OR NATIONAL GUARD ORGANIZATION? L YES LE NO IF "YES." COMPLETE THE FOLLOWING:

GRADE AND SERVICE NO.

SERVICE AND COMPONENT

ORGANIZATION AND STATION OR UNIT AND LOCATION

HAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY. DRAWING FULL PAY, FROM WHICH YOU WERE DISCHARGED OR SEPARATED TO CIVILIAN STATUS? L YES L NO

IF "YES." COMPLETE THE FOLLOWING:

COUNTRY

SERVICE

COMPONENT I TIF ROM (Date)

TO (Date)

TYPE DISCHARGES OR SEPARATIONS-GRADE AND SERVICE NO

ЗаБои ко надвентой

EDUCATION (Account for all civilian' schools and military academies. Do not include service schools)

MONTH AND YEARNET CORN-

NAME AND LOCATION OF SCHOOL

YES

GRADUATE

NO

DEGREE

Sep

, 49

Jun-53. 70.ChristopheracolumbuscHigh-School,Bronx,NIYa x

Academic

Sap

' 53

Jun 55

Queens Collage, Queens, New York

Sep 55

Jụn 58

The City College of New York, New York, NaYa X

BaAa

Sep 50 net Jun 59

Syracuse University.Syracuaa, New York

"i the person is not a f'S, citizen by birth, five date and porf of entry, alien registration number, naruralization sertificate

number and place of issuance.)

RELATION AND NAME

DATE AND PLACE OF BIRTH

PRESENT ADDRESS. IF LIVING

U.S. CITIZEN

FATHER

YES

NO

25 May 1898

Fred Scheer, co her. TanGermany arusuo comicre Debeadedia

- CITfU

X

MOTHER (Maiden name)

24. Apr 1900

2860 Bronx Park East

Ida-Kuran

Bronx, New York

X

SPOUSE "(Maiden name)

Anne Weills

Fab 1942

Eureka, Callf.

2828 Milvia Street

Berkeley, Calif

OTHER (Specify)

None

Hou Mounta

1114

NV 3863 Docld8153013₽

ale 6 PREVOUS EDITIONS ARE OPSOLETE.

poLE: (fininth/s Anti- Exception to Standard Form 86

if the Budget June 1960

---

## Page 7

bro:hers- snu sisters

RELATIONSHIP AND NAME

None

ni linoles.

ENDS LIVING IN FORFIGN COUNTRIES (Lit grandparents,

and aéira parsers

first corsins, aur.

with whom a close relaiionship reisted or exi:

ADDRESS T

CITIZENSHIP

12.

DATES

FOREIGN TRAVEL (Other than as a direct result of United States military duties)

COUNTRY VISITED

FROM-

Aug 1960

Jan

63

Feb

1965

13.

FROM-

Soring

1952

1956

Sep 58

Sep 60

Sep 61

Jun 65

то-

PURPOSE OF TRAVEL

Sap 1960 Cuba

To laarn to urita

Mar 1963 England, France, Polande

Wilte

Hungary, Soviert Union

Mar

& Czechoslavkia

1965

Vietnan, Canbodie, Indonesia

Write

EMPLOYMENT Show Every

MONTH AND YEAR

y empidyment you have had and all periods of unemployment)

TO

NAME AND ADDRESS OF EMPLOYER

NAME OF IMMEDIATE

SUPERVISOR

S. Kleins

Jan 1953

14th Ste New York, New York

Unknown!

1957

U. S. Post Office

New York City, New York

Syracuse University

Jun 59

Syracuse, New York

Unknown

Unknown

Jun 61

Univorsity of CallP.

Berkelay, Calila

Unknown

Dec 63

City Lights Bookstore

251 Columbus, SoFa, Cal1P.

MroLoFerlinghetti

Rempert'e Magazine

Present

301 Broadway, SeFe, Callf.

We Hinckle

REASON FOR LEAVING

Christmas over

School

253

DID ANY OF THE ABOVE EMPLOYMENTS REQUIRE A SECURITY CLEARANCE? • YES X% NO

DO YOU HAVE

ANY FOREIGN PROPERTY OR BUSINESS CONNECTIONS, OR HAVE YOU EVER BEEN EMPLOYED BY A FOREIGN

GOVERNMENT, FIRM, OR AGENCY?

IF THE ANSWER TO ANY OF THE ABOVE IS "YES,' EXPLAIN IN ITEM 20.

HAVE YOU EVER BEEN REFUSED BOND? J YES

SOCIAL SECURITY NO.

112-28-1134

14.

CREDIT•

CREDIT AND CHARACTER REFERENCES (Do not include relatives, former employers, or persons living outside the

United States or its Territories.

TaC

,IS'ENAME

YEARS.

J? a List 3 credis and s character. OCEAKNOWN

STREET AND NUMBER

' (Business: address preferred)

None

Tar

{30

100S 810

11PA: 5a01

F13!

STATE OR

_TERRITORY

jr?s

Röbest Avakian

CHARACTER

" David Welsh

Sol Stern

Robart Trushalt

Malcolm Bernetein

30200005

I WAN

IR

ülef

unknown"

30r Broadgay

301 Broadway

Truenaft & Walker

rueneft&

For Orticial Use Only

"ir.

"r..

iT"Barkelay

1 San Franciace

San Franelaco

Dekland

Oakland

Calff.

Califo

Calli.

NW 88613 Docld:34530159 Page 7

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## Page 8

1 ARE OWES WINTONS A CALLO ON ANOR WHEN MONTANA REFERTAR EN ON TOTAL LO TE ATE SATES OR UPON YOUR SUITABILITY TO PERFORMI

See Remarks

20. REMARKS

PIC :53.?

1,33°

ITEM #12, FOREIGN TRAVElar Continued)

ONE dOOK!

:xucFeb. 1966 to Mar 1966 viatnem, Combodia, thatlond end Japen

CRATES

- Write

I refuse to answer questione 16, 17, and 19 on the grounde that they violate my

constitutional rights under the lat, 15th & 14th amendments to the United States

constitution..u ru

200 se

LUE CIFA

270 22

21: 10n!!

Robert Scheera registant under the military Training

and Service Aet, refused to complete DD Form 398 in 1ts

entiraty.

Chit Wayen

MYRON K. HAYASHIDA

1/LT, AGC

I CERTIFY THAT THE ENTRIES

(See U.S. Codo, title 18, section 1001)

DATE

MADE BY ME ABOVE ARE TRUE

SIGNATURE OF PERSON COMPLETING FORM

5 Oct 1966

21.

1515 Clay Ste Dakland, California

BRIEF DESCRIPTION OF DUTY ASSIGNMENT AND DEGREE OF CLASSIFIED MATTER (top socret, secret, etc.) TO WHICH APPLICANT WILL REQUIRE ACCESS

THAT 1834

40!107

DATE OF CLEARANCE

j..a

/0!G

TaCon 10140100.100:

., i!

RECORD OF PRIOR CLEARANCES:

TYPE OF CLEARANCE

AGENCY THAT COMPLETED INVESTIGATION

REMARKS.

NW 88613 Docld:34530159 Page 8

::17

U.S. GOVERNMENT PRINTING OFFICE: 1960 0-57345

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## Page 9

15.

MONTH AND YEAR TORET

1949119

1958

1959

1961

1963.

1964

1965

41958

1959

1951

1963

1963

1965

Present

÷

LIST ALL RESIDENCES FROM F JANUARY 1837

J: STREET AMO, NUMBER F ini.

CITY

653 Britton Street, Erdnx"

New York" H

Spracuse NiY. Merried Student Houadng Syracuse

Franciaco Street

Berkeley

2157 Mason Street

San Francisco

444 Columbus Street

San Francisco

332 Castro St. & 2870 Geary

San Francisco

2828 Milvia Street

Berkelay

STATE OR COUNTRY

New York.

New York'"'

Calliornia

California

California

California

California

-=.

16.

PAST AND/OR PRESENT MEMBERSHIP IN ORGANIZATIONS

TYPE

(Social, Iratornal, profeasional, etc.)

NAME AND ADDRESS

See Remarks

OFFICE HELD

MEMBERSHIP

FROM

TO

Tro or

17.

YES::

Mosed tit"

tige cindages

ARE YOU NOW OR HAVE YOU EVÉR' BEEN'A MEMBER OF THE COMMUNIST PARTY U.S. A... OR ANY COMMUNIST ORGANIZATIONS ANYWHERET

ARE YOU NOW OR HAVE YOU EVER BEÉN A MEMBER OF'A FASCIST ORGANIZATION?

Dot Pall:.

OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES. OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF

THE UNITED STATES BY UNCONSTITUT/ONG MEANS? *

HUBt

Hutton is

ICES

÷017U0

ARE YOU NOW PR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATÈD WITH ANY, ORGANIZATION OF THE TYPEDESCRIBED ABOVE AS AN AGENT. OFFICIAL, OR EMPLOYEE?

ARE YOU NOW ASSOCIATING WITH. OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS. INCLUDING RELATIVES. WHO YOU KNOW OR HAVE REASON TO BELIEVE, ARE OR

HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE?

HAVE YOU EVER ENGAGED IN ANY OF THE FOLLOWING ACTIVITIES OF ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE: CONTRIBUTION(S) TO, ATTENDANCE AT OR

PARTICIPATION IN ANY ORGANIZATIONAL, SOCIAL. OR OTHER ACTIVITIES OF SAID ORGANIZATIONS OR OF ANY PROJECTS SPONSORED BY THEM: THE SALE, GIFT. OR DIS

SCOTCh TRIBUTION OF ANY. WRITTEN PRINTED. OROTHEBATTER PREPARED: REPRODUCED. OR PUBLISHED. BY THEM OR ANY OF THEIR AGENTS OR INSTRUMENTALITIEST

IF "YES." DESCRIBE THE CIRCUMSTANCES. ATTACH ADDITIONAL SHÉETS FOR A FULL DETAILED STATEMENT. IF ASSOCIATED WITH ANY OF THE ABOVE ORGANIZATIONS. SPECIFY NATURE

16. 1013 146

See Remarks

i8. HAVE YOU EVER BEEN DETAINED. HELD, ARRESTED. INDICTED OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING. OR CONVICTED, FINED. OR IMPRISONED OR

minor traffic violations for which a fine or forfeiture of $25, or less was imposod)?

IF "'YES." LIST THE DATE, THE NATURE OF THE OFFENSE OR VIOLATION, THE NAME AND LOCATION OF THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER

DISPOSITION OF EACH CASE.

19. ARE THERE ANY INCIDENTS IN YOUR LIFE NOT MENTIONED HEREIN WHICH MAY REFLECT UPON YOUR LOYALTY TO THE UNITED STATES OR UPON YOUR SUITABILITY TO PERFORM

THE DUTIES WHICH YOU MAY BE CALLED UPON TO TAKE OR WHICH MIGHT REQUIRE/FURTHER EXPLANATION? |

IF "YES." GIVE DETAILS

NW 88613 Docld:34530159 Page 9

See Remarks

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