Part 26, page 41

Transcript

The scan is the source; the transcript is machine-generated from it.

CASE SERIAL NO. LCSC use only

19. HAVE YOU EVER HAD A NERVOUS BREAKDOWN OR HAVE YOU EVER HAD MEDICAL TREATMENT FOR A MENTAL CONDITION? ☐ YES ☒ NO. (If your answer is "Yes," give details in item 28.)

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20. FOREIGN COUNTRIES VISITED (SINCE 1930). (Exclusive of military service.) COUNTRY DATE LEFT U.S.A. DATE RETURNED U.S.A. PURPOSE None

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21. ARE YOU NOW, OR HAVE YOU EVER BEEN, A MEMBER OF THE COMMUNIST PARTY, U.S.A., OR ANY COMMUNIST OR FASCIST ORGANIZATION? ☐ YES ☒ NO.

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22. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY FOREIGN OR DOMESTIC ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP, OR COMBINATION OF PERSONS WHICH IS TOTALITARIAN, FASCIST, COMMUNIST, OR SUBVERSIVE, OR WHICH HAS ADOPTED OR SHOWS, A POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES, OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS? ☐ YES ☒ NO.

23. IF YOUR ANSWER TO QUESTION 21 OR 22 ABOVE IS "YES," STATE THE NAMES OF ALL SUCH ORGANIZATIONS, ASSOCIATIONS, MOVEMENTS, GROUPS, OR COMBINATIONS OF PERSONS AND DATES OF MEMBERSHIP. IN ITEM 28 OR ON A SEPARATE SHEET TO BE ATTACHED TO AND MADE A PART OF THIS FORM, GIVE COMPLETE DETAILS OF YOUR ACTIVITIES THEREIN AND MAKE ANY EXPLANATION YOU DESIRE REGARDING YOUR MEMBERSHIP OR ACTIVITIES.

NAME IN FULL ADDRESS FROM TO OFFICE HELD

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24. MEMBERSHIP IN OTHER ORGANIZATIONS. (List all organizations in which you are now a member or have been a member, except those which show religious or political affiliations.) (If none, so state.)

NAME IN FULL ADDRESS TYPE FROM TO OFFICE HELD b6 Per BOC None

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25. RELATIVES. (Parents, spouse, divorced spouse, children, brothers, and sisters, living or dead. Name of spouse should include maiden name and any other names by previous marriage. If person is dead, state "dead" after relationship and furnish information for other columns as of time of death.)

RELATION NAME IN FULL YEAR OF BIRTH ADDRESS COUNTRY OF BIRTH PRESENT CITIZENSHIP Father Mother Wife Daughter Daughter

Ex-Wife

Brother Sister b6 Per BOC b7C Per BOC

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DB Cooper-7194