CURRENT RESIDENCE AND DEPENDENCY REPORT - MILLS, MONTRELL EUGENE

• Document Type: FOIA
• Keywords: MILLS MONTRELL E
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001308900
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Release Date: February 19, 2008
• Case Number: F-2005-00558
• Publication Date: March 14, 1966

 (b) (3) (b) (6) (t~corded on~ts~l                  to                ns   Ilo               n with leave at o e me  expens  ov s as   y, return   e     e up    e a atin,     or    idi   urre res   c  n   peen  ncyinfor- motion re  iredin theeve t     employee emergency.T eoriginalofthi s fo m    be fi   in t eemplo  eicial prsonnel folder NAME OF EMPLOYEE   (Last)                                  (First)         (Middle) SOCIAL I /                                    ESIDENCE DATA ? PLACE OF RE IDF~iCE WHEN INITIALLY E     O ED BY           ENCY \j,~ LAST PLACE OF RESIDENCE IN CONTINENTAL U.S. (11 appointed abroad) gn-" PLACE IN CONTINENT L U.S. DESIGNATED AS PERMANENT REST- DENCE HOME LEAVE RESIDENCE 2.                                                         MARITAL STATUS (Check one) SINGLE                    MARRIED                  SEPARATED               DIVORCED                    WIDOWED                 ANNULLED IF MA       D, PLACE OF   A    IAGE DATE OF MAR)iIAGE IF  IVORCE   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 NAM,0       SPOUSE M ADDRESS (No., Street, City, Zone, State) vC/v"l! TELEPHONE NO.. J           d L) 3     . NAMES OF CHILDREN N710 5,c-~ ~o -vq M 111 s , I l o b o r_-. G. _-I (S, _  wa s S ADDRES~ 4 Pc.,,,, 0L ' r SEX 1" /-n DATE    BIIiTH P. 9   ` ) 9 ws''~ NAME      Y MA     UR FAT  E WeI0 guardian) ADDRESS k TELEPHONE NO. NA                               Y PR MOT ER fame   g   r !en) ADDRES TELEPHONE NO. WHAT MEMBER S) O YOUR FAMILY IF ANY, HAS BEEN TOLD OF YOUR AFFILIATION WITH THE ORGANIZATION IF CONTACT IS RE- QUIRED IN AN EMERGENCY. 4.                                                  PERSO TO BE NOTIFIED IN CASE OF EMERGENCY NAME (Mr.,.M>., Mice)  (Last-F   st  iddie) Tomiar- REL                     NSHIP HOME ADDRESS      , Street,                  fete) ecl HOME TELEPHONE NUMBER BUSINES  ADDRESS (No., Street, City, Zone State) A      D NAME OFCEMPLp  W  ,..LF APPLICABLE BUSINESS TELEPHONE & EXTENSION IS THE INDIVIDUAL NAMED ABOVE WITTING OF YOUR AGE  CY AFFILIATION?   It `No' give name an                       address of organiza- tion he believes you work for.) YES NO IS THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (I! ?No' give name and address of person, if any, who can make such decisions in case of emergency.) YES NO DOES THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE?  (If answer is 'No* explain why in item 6.) YES 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   1  USE PREVIOUS EDITIONS. CONFIDE( IAL (4) APPROVED  FOR RELEASE DATE:  NOV 2007 CO    ENTIAL (When F   dIn) 5.                                                    VOLUNTARY E     ES Experience in the handling of employee emergencies has shown that the absence of certain personal data often delays and compli- cates the settlement of estate and financial matters. The information requested in this section may prove very useful to your family or attorney in the event of your disability or death and will be disclosed only when circumstances warrant. INDICATE NAME AND ADDRESS OF ANY BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS AND THE NAMES IN WHICH THE AC- COUNTS ARE CARRIED. ARE YOU A MEMBER OF THE NORTHWEST FEDERAL CREDIT UNION?             YES           .NO IF YES, DO YOU HAVE A JOINT ACCOUNT?                                YES            NO HAVE YOU COMPLETED A.LAST WILL AND TESTAMENT?   a, YES        -WO.  (If `Yee" wherein document located?) HAVE  OU PREPLANNED AN ARRANGED GUARDIANSHIP OF YOURCHILDREN IN CASE -OF COMMON DISASTER TO BOTH PARENTS? F '17f YES        NO. (It  Yea  give name(s) and address) HAVE YOU EXECUTED A POWER OF ATTORNEY?   Q YES  [.~~110. (11 *Yea*, who, posseae the power of attorney?), e?                       ADDITIONAL DATA AND/OR CONTINUATION OF PRECEDING ITEMS SIGNED A DATE SIGNATU CONFIDENTIAL