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PART I COMPENSATIONt ANID WITMOLDINCG DATA ______________
4. COVPATION PAV'%¶l.T-S nY c0VrR F KIL [TY
TOT.L -OAUl' (F.r 0 .... A.0 ''I FC TO tax V411 AI I EV ~% 1; .f AT TS TO atGIeA foat.)
9,60 :BY VN p15 July,1961
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4. TAE-T EWITHHELD B3Y COVER FACIL ITY FP.Cf CCO FNSATI('N PAID
ICOUC TAXtS.* AMOUN1T*-eI-IO PER PAY PCBIOO IS SOCIAL SCCIJNITY IfICA) MIIMNLD..
COUPEN ATJION SIAJE ,CT TO A FOREIGN TAXI' NAEO UITR
COVER, FACILITY WILL. REPORT COMP'ENSAT ION AS FOLLOWS ISe t, below)
aWIL L NOT.R[POR? I I FORM W.l a~ J Fonts got$
COVER FACILITY CPn
B. THE AGENCY' WII. REPORT -COMPENSATION AS FOLLOWS (See it#- If el.
-COVERT i cvet nly, 0-1 ve 1 the 'i#.]
10. - DCL:ARATION OF ESTIMATED INCOVE TAX (Check 0la)
1.4ASBEEN0 F`ILED_ - AS,NOT-BEEN FILED JA OT APPLICABLE
-PART 11 DEPENDENCY DATA
II O f' EPENOENTS, INCL IN$EF LIE'iTCOE NOOfDPNET.ICUN SF LAMDN
f3. _ -MARITAL STATUS (Capletv as opptoptatv)
SIOEiIAnOIED IWIDOWED I DIVORCED
OATC'OF DEATH DATE Of DECREE I -LErALLY SEPARATED
I I ANNUJLLED
61VIASIIP oF SPOIJ31 RESIDENCE Of SPOUSE (C---#fY)
14 DEPENDENTS ELIGIBLE TO BE CLAIMED FOR PURP'OSES OF FILIIT, TAX RETURNS WHO MAY OR MAY NOT BE INCLUDED
IN NUMB3ER OF DEPENOTS-DECLARED ABOVE (O.1t ealf ..d OR....e
_1LATIO.M34IF (NO ee)lTCTIESP COUNTYF RSIEC
IS. APPROVAL OF CENTRAL COVER DIVISION 17. FOAM PgEFAAEO BYISTIo. CIS.
DATE SIGNATURE AND TITLE .,~~. PART I CERTIFIED CORRECTie ht l SjWI
- ~~~DATE TIGNIASUBE OF INDOIVIDUAL(aed ,)
VISTRIEUTIIYI SIGNED CR16. AJVD COPY T0r FINANCE: COPY TO CFiIENAL COVER: COPY TO FILE
::313a esseLcTa pSERIBus BFBI SECRET IO
SECRET
PART II I
NOTE: DETACH THIS P6RTION OF FORM AND DISTRIBUTE SEPARATELY 4.
1.SCCIAL SICUBITS NO0. IV SOCIAL 5ECURIrf NO. IS 14OT AVAILA5LE, HAIE F~rM NO -- go'0 CITSEI
A PPLICATI01A FOO SOCIAL SECRiqlTY -CCOL'%FS. * CCIPLETEO AS
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