(EST PUB DATE) CURRENT RESIDENCE AND DEPENDENCY REPORT - MILLS, MONTRELL EUGENE

• Document Type: FOIA
• Keywords: MILLS MONTRELL E
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001308750
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Release Date: February 19, 2008
• Case Number: F-2005-00558
• Publication Date: January 1, 1954

 (When (b) (3) (b) (6) Complete in duplicate. The data recorded on this form is essential in determining travel expenses allowable in connection with leave at government expense, overseas duty, return to residence upon separation, and for providing current residence and dependency infor- mation required in the event of an employee emergency. The original of this form will be filed in the employee's official personnel folder. NAME OF  MP  OYEE     (Last)  /'                          (First)                               (Middle)  SOCIAL SECURITY NUMBER S                 Y 1.                                                                     RESIDENCE DATA P PLACE OF RESID CE WHEN INITIALLY EM   DYED BY AGENCY LAST PLACE OF RESIDENCE IN CONTINENTAL U.S. (If appointed &-"'l k g, abroad)                                01_ PLACE IN CONTINENT. 4L U.S. DESIGNATED AS PERMANENT REST- OME LEAVE RESIDENCE DENCE             J 2.                                               MARITAL S TATUS (Check one) SINGLE                        ARRIED                    SEPARATED DIVORCED                     WIDOWED                  ANNULLED IF MA      D, PLACE OF t4APRIAGE DATE OF MARRIAGE IF     IVORCED  PLACE OFD              ORCE DECREE DATE OF DECREE IF WIDOWED, PLACE SPOUSE DIED DATE SPOUSE DIED IF PREVIOUSLY MARRIED, INDICATE NAME(S) OF SPOUSE, REASON(S) FOR TERMINATION, AND DATE(S) 3.                                                                    MEMBERS OF FAMILY N M  O     SPOU E ADDRESS (No., Street, City, Zone, State) TELEPHONE NO. NAMES OF CHILDREN Ph 1)5, Z'V   ,rvy i, ADDRESS )! 4 y SEX 1 DATE    BIpTH Ist (1'obQ 41  G. &             15Ali m 12   `S - N~~~Irsl NA E       Y  UR FA  H    (      Is guardian) TELE PHONE NO. :::::: NA E       (IUR MOTHE '  It fem g r ian) TELEPHONE NO. WHAT MEMBE  (S) OF YOUR F        MI  Y IF ANY, HAS BEEN TOLD OF YOUR AFFILIATION WITH THE ORGANIZATION IF CONTACT IS RE- QUIRED IN AN EMERGENCY. 4.                                                      PERSON TO BE NOT FIED IN CASE OF EMERGENCY NAME (Mr-Mrs., Miss) as -F s   iddle) RELATIONSHIP it ~ t HOME ADDRESS     ., Street a, State) HO    TELEPHONE NUMBER /41 IQ             et_-d duA-~,. 5~-~ A&;eh BUSINES  ADDRESS (No., Street, City, Zon , State) AND NAME OF EMPLOYER, IF APPLICABLE BUSINESS TELEPHONE & EXTENSION e~0 IS THE INDIVIDUAL NAMEDABOVE WITTING OF YOUR AG CY AFFILIATION?  If 'No' give name- ap4 address of organiza- YES tion he believes you work for.) NO IS THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (If *No* YES give name and address of person, if any, who can make such decisions in case of emergency.) NO DOES THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE? (1f answer is eNoM explain why in item 6.) YES JP_ NO The persons named in item 3 above may also be notified in case of emergency. IF SUCH NOTIFICATION IS NOT DESIRABLE BE- CAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE IN ITEM 6 ON THE REVERSE SIDE OF THIS FORM. CONTINUED ON REVERSE SIDE CURRENT RESIDENCE AND DEPENDENCY REPORT FORM F'~  USE PREVIOUS v EDITIONS. APPROVED FOR RELEASE DATE: NOV 2007 CONF