U.S. DOCUMENT REQUEST FORM.
Originator: CIA
To: FR/SG
Document date: 10/19/1972
Document type: PAPER - TEXTUAL DOCUMENT

## Page 1

4300000

104-10121-10213

Case No.

¡Do not write in this space)

• 2022 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992

Date: 19 Oct 72

Requesting Office:

U.S. DOCUMENT REQUEST FORM

REQUESTS FOR U.S. ALIAS DOCUMENTS FOR USE IN U.S.

REQUIRE APPROVAL OF OFFICE OF SECURITY

FR/SG

Ext: — 4412

Date Documents are required: ASAP

07

Registered Alias:

Miguel Perez COSSIO

(Write out middle name, if any)

Backstopped address, if any:

If address is to be selected by TSD, list state and cities with which you are familiar in order of preference:

First choice:

Second choice: -

(Maryland Driver's License

10

Third choice:

Height:-

5'11" Weight: 198

Glasses while driving? No

Occupation: -

Hair:-

Brown Eyes: Brown

Birth date: 26 August 1925

(Engineer, Intelligence Officer, Government Official, etc.)

_ Blood Type: A

Married? Yes

Place: Phoenix,

a Arizona

• Mexican

(White, Negro, Yellow)

Specify country where documentation will be used: -

Documentation requested:

(ary lana) License Jana Social Security)Card.

bitter pertinent

Mentan

Clubs shots tes.

&-1k

As a guide for issuance of appropriate documents, list hobbies, i.e., photography, bowling, shooting, stamps, etc.,

special interests, social clubs, athletic and cultural associations, or professional societies or institutions with which

you are familiar:

Signature exemplar in alias:

(Write name three times)

Supply proper photo or negative for identity document request if required.

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