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104-10131-10041 JFK Assassination Records Archives 1 (7/16/1970)

handle is hein.jfk/jfkarch11603 and id is 1 raw text is: 
1


To  avoid delay-1.   Read  information carefully;   2. Complete   application in full;   3. Typewrite  or  print in ink
                                            A. PERSONAL INFORMATION
I. NAME        (Last)             (First)             (Middle)         2. DATE OF BIRTH            3. SOCIAL SECUR NUMBER
  MR                                                                     (Month) (Day) (Year)
              TARASOFF             Boris              Dimitri          Nov        2      1908

4. ADDRESS             (Number and street)                      (City and State)                        (Zip Code)

  CORREs:    ancho Contento. S. A., Apartado Postal 2707, Guadalajara, Jal., Mexico]

  CHECKS:  Union Trust Company of the District of Columbia,                          .0.   Box   481, Ben
           Franklin Stn. , Washington, D. C.                 20044        (Acct,      -110-545):
S (A) ARE YOU    6. (B) IF YES. GIVE THE FOLLOWING INFORMATION:                           OS      -
     MARRIED!
               WIFE'S OR HUSBAND'S NAME HER (OR HIS) BIRTH DATE DATE OF MARRIAGE  ADDRESS OF SPOUSE IF DIFFERENT FROM ITEM 4
                 (First)      (Middle)  (Month) (Day) (Year) (Month) (Day)  (Year)
     YES
  OINO           Anna                    May 5         23 Mar 10 45               N/A
                                                B. CIVILIAN   SERVICE
1. OFFICE OF ASSIGNMENT                    2 SERVICE DESIGNATION 3. LOCATION OF EMPLOYMENT (City and State)

    DDP/WH                                        D                   Mexico City
4 TITLE OF LAST POSITION          ..   S.   DATE OF.FINAL. SEPARATION (Month) - (Day) (Year)  6. APPROXIMATE NUMBER OF YEARS OF
    Staff  Agent                                                  Nov   30  1970            CIVILIAN SERVICE 15
7. DO YOU HAVE FEDERAL EMPLOYEES GROUP LIFE INSURANCE?- 8. ARE YOU ENROLLED IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS
                                        YES    l NO      PROGRAM?                                          YES    L NO


                                                C. MILITARY SERVICE
I. COMPLETE THE SCHEDULE BELOW IF YOU HAVE PERFORMED ACTIVE DUTY THAT TERMINATED UNDER HONORABLE CONDITIONS IN ANY OF THE FOLLOWING SERV-
  ICES: (A ARMY. NAVY. MARINE CORPS, AIR FORCE. OR COAST GUARD OF THE UNITED STATES: OR (B) REGULAR CORPS OR RESERVE CORPS OF THE PUBLIC HEALTH
  SERVICE AFTER JUNE 30, 1960: OR (C) AS A COMMISSIONED OFFICER OF THE COAST AND GEODETIC SURVEY AFTER JUNE 30. 1961. IF AVAILABLE. ATTACH A COPY OF
  YOUR DISCHARGE CERTIFICATE
  BRANCH OF SERVICE       SERIAL NUMBER    DATE OF ENTRANCE DATE OF SEPARATION  LAST GRADE      ORGANIZATION AT DISCHARGE
                                            ON ACTIVE DUTY  FROM  T.IVE DUTY     OR RANK             (Div., Regt.. Co., etc.)
                                                                                                16th  Reuforcene'
U.  S.  Army            20  248   288        3 Feb 1941 20 Oct 45              Tec   4                Depot



2. (A) ARE YOU A MILITARY RE-  2. (B) ARE YOU IN RECEIPT OF OR HAVE YOU EVER APPLIED FOR  2. (C) IF YES, WERE YOU RETIRED FROM A RESERVE COMPO-
    SERVIST (EITHER ACTIVE     MILITARY RETIRED PAY? (RETIRED PAY DOES NOT IN-     NENT UNDER CHAPTER 67, TITLE 10. U.S.C. (FORMERLY
    OR INACTIVE)?        _  . ..CLUDE V.A. PENSION OR COMPENSATION.)           TITLE III, PUBLIC LAW 0-8101?

    O]  YES      NO                           YES      NO                                    O]YES        NO
                                           D. DISABILITY INFORMATION


2. BRIEFLY DESCRIBE YOUR DISABILITIES. STATE WHEN INCURRED, AND HOW THEY INTERFERE WITH PERFORMANCE OF THE DUTIES OF YOUR POSITION. (ATTACH
   ADDITIONAL COMMENTS ON PLAIN SHEET OF PAPER IF NECESSARY.)                           R     URNTO     CIA

                                                                                     Baakground Use Only
                                                                                       DO  Not  Reproduce

                                           E. OTHER CLAIM INFORMATION
 1. (A) HAVE YOU EVER RECEIVED OR MADE APPLICATION FOR COMPENSATION I. (B) IF YES. STATE THE NUMBER OF YOUR COMPENSATION CLAIM AND THE
     UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT?               PERIOD FOR WHICH YOU RECEIVED COMPENSATION
                                          E YES     M~NO        CLAIM NUMBER     FROM (Month) (Day) (Year) TO (Month) (Day) (Year)
                                              -             O              YEN
2. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIVIL SERVICE 2. (B) IF YES, INDICATE THE TYPE(S) OF APPLICATION
     RETIREMENT SYSTEM. INCLUDING APPLICATION FOR RETIREMENT, REFUND,  AND GIVE THE CLAIM NUMBER(S) IF KNOWN    CLAIM NUMBER(S)
     DEPOSIT OR REDEPOSIT. OR VOLUNTARY CONTRIBUTIONS?        O  RETIREMENT     DEP S O   RD   O
                                                                  E  REIREMNT U DEPOSIT OR REDEPOSIT
                                          O  YES       NO     O  REFUND         CON  TBABRTONS
3. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIA RETIRE- 3. (B) IF YES. INDICATE THE TYPE(S) OF APPLICATION:
     MENT & DISABILITY SYSTEM, INCLUDING APPLICATION FOR RETIREMENT.
     REFUND, PURCHASE OF SERVICE CREDIT, OR VOLUNTARY .CONTRINIONS.      RETIREMENT         PURCHASE OF SERVICE CREDIT
                                           O  YES       NO           O  REFUND          O   VOLUNTARY CONTRIBUTIONS
4. (A) HAVE YOU EVER BEEN EMPLOYED UNDER ANOTHER RETIREMENT SYSTEM  4. (B) IF YES. GIVE THE NAME OF THE OTHER RETIREMENT SYSTEM
     FOR FEDERAL OR DISTRICT OF COUMBIA EMPLOYEESi YES O) NO     Civil   Service System


Only  applicants for  total disability retirement will
complete  Part D.


WHEN DID YOU BECOME TOTALLY DISABLED!          (month. ye'ae)


A[ LICATIQN FOR RETIREMEI

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