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104-10180-10219 JFK Assassination Records Archives 1 (09/22/1961)

handle is hein.jfk/jfkarch75393 and id is 1 raw text is: 
1104-10180-10219  12022 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992



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       1 AI- .                     I'       ~iio  :Aorico Rodrie'L.oz 0 /bf                              't j., I          k


  l0.    -                      DECLARAT ION OF ESTIMATED  INCOME TAX (Chock  0n0)

      HASNBEN FILED         -     .        HASNOT-BEEN FILED                    NOT APPLICABLE
                                      -PART 11 DEPENDENCY DATA
  11.. ND. or DEPENDENTS. INCLUIIG SELF. CLAIMED WiITH COVER  IS. NO. Of DEPENDENTS. INCLUDING SELF. CLAIMED ON
     FACILITY.            ,.*FORM Ill ON B-A (0' oquieolent) ATTACHED

  IS.                              - ARI TAL STATUS (Cooplot. o aspprop..Aeto)

  fF, SINGLE               -      MARRIED                   WIDOWED                     DIVORCED
      DV gl     pAT' o j        ATE'OF DEATH             DATE OF DECREE                 -LEGALLY SEPARATED

  OFD SF01131 R(I:NC                                                                    ANNULLED

  i 6ITIAENSHIP OFSOS                                     EIEC      fSPOUSE (COumcft)


  I4. DEPENDENTS ELIGIBLE TO BE CL'AIPMED FOR PURPOSES OF FILIN, TAX RETURNS WHO MAY OR MAY  NOT BE INCLUDED
     IN NUMB3ER OF DEPENDENTS'DECLARED ABOVE  (0.11 eel( end *pOHOO)

     F LATIONSHIP (ANo no.00)            0  BIRTH                r. TiZE SNIP           COUNTRY 0? RESIDENCE


                                                                   .  -'                                        '   0






  dIast.       APROA                                                    O0 CETA                         OE0IIIN             1.FR     RPRDB              or~u        orc



                   PAS.                                                     I ERTFIDRRREC










 DATE         SIGNATURE AND TITLE                   ..  PART  II  CERTIFIED CORRECT  (Explain .hv, not *ijnedl
                        G ATE                                                  SIGNATURE OF INDIVIOUAL (~~o .




            DISTRII0IO   SIGNED   ORIG. A.VD COPY ' TO FINANCE: COPY r O CFEMNA). COvER: COPY TO FILE

r~e:: 313a .eeatTt pOecwtou traIte,*.             SECRET                                                IfO)



                                                   SECRET

           `                                       PART 111


1


NOTE:    DETACH  THIS   PORTION   OF FORM   AND DISTRIBUTE SEPARATELY                        tc


I  CCIAL SECURITY NO.  IF SOCIAL SECURITY NO. IS NOT AVAILA9LE, HALE F04M NO. SS-5. Z0 CITIZENSHIP,
                        'APPLICATION FOO SOCIAL SECLIQITT »CCOU'S. * COMPLETED AS
                        PROvio['1I DETAILED PROCEDURES.                              f0e so


'II. AbOWEII OF RLCOND (l. U.S.)      o6               22. ADDRESS (te,.ljnA


  c9 361 178th   St.  Perrino,      M'Arida                                           N

            OISTRliPCTIOV Sli+%ED OEIC A.%TD cop? TO FA WEc: Corr r7 cENr AL COVER: COPY -TO FILF


 °IT 3 13a IIIR~ITI ,t.ION /IISIRW.               SECRET                                                                  Ie


                                _PART   I  COMPENSATION AND WgTHMOlLoIprG tATA  ______________
                          S  OVTIdS 01 CO}~'EtiAT IiO PAV+*'%T~ FCA'.c& ,...roPr.At.I.

    HEAoQOARIERS                T    u  AuDILAIL TMIYT                             '_i      1lerercaCIT,
4.-                               COYIr.5SATION PA~vfl.1' fY Co'/rH FACILITY       -
TOAL *.DUNT (P~r ,Bne+,)  £AYO.'   ,jsC, TO TAA :f XPLAIN AN( ,IFF.EN F' t.*:ro GF PAVrt~TS TO [teIN (Derr)
  9,600                      7,   (              :ea     -P.T AE N fl.E AN.T AN* Ti     5Jl        16
       T                                                      :B.T GIYINS, TYPE CF PAY s RS    15 July 16
                                                  (All... ...  r .).
         N. PAY -PERIODS USED PY COVEN FAILITY

   Re[[LY                             slWERL               s/IFIMNTwLVf               MONTHLY
      t.              TAXES_ TO BE WITHHELD  BY COVER FACILITY FRCM. COY'PENSAT IC'N PAID








    B             COVER, FACILITY WILL REPORT  COMPENSATION AS FOLLOWS  (S.. It.. If below)






    s.               THE AGENCY64L REPORT.COMPENSATION AS FOLLOWS (So. it.. 16 bolo.)
    COVERT (lI cover, onIY,. o.lIroo t of tAle It...)     rO~R.                       ro.,. IoNss

NAME. AHD-ADDRESS .OF OSESL ~         q upllI~9 R                                                                                        c

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