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United States Department of Stat

Washington D.C. 20520

JUt 292011'

In reply refer to:

CA/PPT/L/LE - Case Control Number: 200807238

Christopher E. Strunk

593 Vanderbilt Avenue, #281 Brooklyn, NY 11238

Dear Mr. Strunk:

The following is in response to your request to the Department of State, dated November 22,2008, requesting the release of material under the provisions of the Freedom ofInfonnation Act (5 U.S.C. § 552).

We have completed a search for records responsive to your request.

The search resulted in the retrieval of six documents that are responsive to your request. After careful review of these documents, we have determined that all six documents may be released in full.

We did not locate a 1965 passport application referenced in an application for amendment of passport that 1.S included in the released documents. Many passport applications and other non-vital records from that period were destroyed during the 19808 in accordance with guidance from the General Services Administration.

Passport records typically consist of applications for United States passports and supporting evidence of United States citizenship. Passport records do not include evidence of travel such as, entrance/exit stamps, visas, residence permits, etc., since this information is entered into the passport book after issuance.

Thiscompletes the processing of your request.

olbin, Director

Office of Legal Affairs arid Law Enforcement Liaison Bureau of Consular Affairs

Passport Services

Enclosures:

As stated

----- --

FQ.R'" ,,""R·OVEO .

"1:J D'S-.E T BU,R·E."'U .,."'. A7·R·' 17'.5

Djakarta. Inoonesia

POST ~~-=- __:'=--~~~~ _

o REF,ERHED TO" DEP'ARTI.1Et-IT FOR >!.eTION_ BRENE\\!,ED{~) TO Jul.1B,1970 D, AMENDED AS. ,REQ'UESTEiEI

FOREIGN SERVT,CE '0,1" THE U.iIT~O. S'rA.TE;; OF '~,o,1ERICA

RE~'EWAIOF

A.5'SPO'RT DCARD Q',F ID~NTITY

EG'IS~Tl(iH ',0 C'E,RTIFfCATE O-F _l£EI'ITITY ,_

Docu,ment No .. ,;C 7777 if.3 DQt .. '~""ued Jw_y / f 1'1(;

APPUCATlOH .FOR,

D AMENDMENT DEXTENS10N

s 5.00 F'EE (OO'LLE,CTED o NCOIO-E.E Cr::JLLECTEIll

s

CI:I

'~ ~ __ ~~ ~~--~~~~--~770c-.-~~~~~~~~~~-=~,------, __ --------~m

H,

_ P-RO-RIilSE D, T R A'V EL- PLAN S

I INTEN 0 TS' ,CONT i!"!JE T'O RE.SI'OE AEI''R'0 '" O,'-FOR' THE Fo.L-L OWlN'G' !'M.M,E 0 I" "'HI P 'il'F,' AIRLI,NI;;'

-PERLOD,ANtI PURP'Q:s'l;; /N,VEFIIV/tTE-/lf41i!l!/1ED

70 AN )jV DO 1\1 £5: /4 A/ Cllr ZElJ ~D-,A'-T-;E-'-6-."'-'D-'- E-."-"'-R'T-U-H-E-------------I

I hac'!:" not, Q1nd fio "'ib~r Be,,,"oD ,lnqwt",d~,~"ro Ji,~_jndud-~:a i,Q.' til" p:::p;'simft 1ft d'P'c~ej'<l',i\'Q h;"s), d.nlit aC'lni:f,itrg l:1'oj!.,'C$ta;tes dt'lzenshll! e b',;'ell ,,~airur:~Hi~d is a dtrze'""O'f a :fore,~!w; ~13t:e;,i"lCen' an, "'!IIi! 'lie ll)i1de an aHi.r:monio.. or"':h ... r {o,rmal i:I~"la""tl.On' 01 a)legian"" - to a,for,,,igpsta(<;.-; ,entered "t s,,"v!)d'i,?-,rlie ''''r-",..afe'c,!'-s"of ,ii, for-e,igJ;l s',a>:-!i;,a<i",eplea or,I'""rf~rmed rhe dupe''; oJanyo,ffi"e, PQST, or 'emp),oymellt Wldel! ,he"goyebimen.;'of.,a' fo(eign "I",,'" orpofi't,;c1tl s,ub:divisieo.',rhe'reof; vote d fDa poHti",,1 elec.doll' in. a foreign Slate Or pa',," th:il',ak~d 'ill an, "le4d:'on,oI,~,j .. l,;~u, to 'd,et,e'mfne: ,~e,s,o"~re);g'",(,y ,ove,c ,roJ:'1iS!!,.e,~,i~o<$;,.ma.d~'.a' formal t~",,'ci'ia:dpn o!"l1,~dp.nalitl': .. Lt'bjO.F -in· [he lJni'i.ed S'~.te s orbefore a dip] "ma,t;ic or eons ular oHlce,r 01 th-e United Stare-s in ,3. [oreigrrSt·atc-e; ev~_.[ .so,ught a, cl'airne d lobe -benefi-r-s of"th'e natio",,,ihy of,an}! (Ol'"i,!!";,sfa.te; or.rbe .... n COo''l:icted by'" eOrlrt'o"'CCO:UCC m~"rti~a!, o'(c.ompetent'jUrfs.~h'li'on c·t commj",io.g"aoy':aC[ o,f l[i~asdo. aga 'insr; ,ar arre "llnin'g by to rce ,[o· .. ov;e:,·,b,w.",. 0."- t;...,dng arms agal ns~~~he Uai.ted State's. a, co,t r ;;·pi~ing ['0" .Q·venlir,ow,· ]'i,ucO!(own- 0'1 lo,deiS'noW by loI'~e" the G""","t'nmen~"Qf ,he<~ph"'d. S.,,~'cs.

• (,n- cmy ?_f l/:le a~".".meni;~~d od,s or_."xm:d:i~I"ps h~:e I"'~"Q YUl<m""d bt o~ opply 10 +'I)eoppll~ont, Or to . any oth~r R;"rson Induded

rfl' _If,,, ~"s,,.~,' ,or;Jcr.""""""f<;I".on, :,~,~ p,<;>rt.on ~;'''~ Clpp,('':~ ,sh",yld, b" Sl"'C~ qut., gnd 0 ,s~p~I~"nt'!7 ""'!PI an~~ry, S#at,errre<l1' unaero Qot/; (or' afffhircl't,'on./ By .. ,he pe""on to MrolTl the 'P0ri,on 's Of'pl"cof;re-~lioul'd b,e ctttaehec{- andm"ii<! " p<frto .of tl; ,"$- opp/, d01'n;"./

Su;"sciibe'iJ and, ,S .... <itllto.(affliime'd) ,befp"e 'l)1e r1ii s ---"""¥"'7'T--r+'~' (S£40.L) Vice

Consul _

(The, D"pamli~.n:t ",HI "M5um" .. jh:at rhe Coits'u~ar .. offi.ce.-r._ ': ~Wal".r '10 th·" appJlcant'~ iden,iiy uule.ss a aorarien to the -~on:,"a .. y is'.

FORM FS-2~t9 7 -54

AIo!EN 0 TO I~CLUDE I EXCLiJ DEi IWIFEIIHU!:i8AN OJ

C:D'VQACE' CJ o.EATH

NVM B,ER op· MY :SFI.OUSIE~Si P·RE vrous '" AS,PO_RT

INOd

P f=l:E.-YI OlJ:9 MA R·RIl\"t;:: E T e::~M'IN'A T E q. e-v

AMEND TO INCLUDE (EXCLUDEI C}1ILD.AEN

~~ ~N~"'~M~_~E~S~' ~.- __ ~~ R~E~S_I_O_E_N_C~E~ _, -=a~'I_R_-T_H~P_-_L_"'_C_~E ~ __ -r a_·_IA __ T_H~O~.A~T~'E~ ~

I~~~~

AM,EN.O TO AEAO HI MAAAIEONAM'E

o"TE MARRIED

PLA..C a MARFnEO

D U. s, Ci'TIZEN

OTHER AMENDMENT 15) tOE:SCR!:ElE IN DETAIL ACTION FlE,QUESTED)

o "'-'E .... ·ClT'2.I<N. OF

~OCUMENTARY ENI DENCE SUBMITT EO TO O'EPAATMENT a Y CONSU LA R 0 rFICER

DOCUMENTARY EVIDENC E SEEN AND RETURNED TO APPLICANT BY CON SU '-A R OFF ICE R

ST ATE"MEN T 0 FACT I ON 'SY POST UPON 0 E I'll RTM,ENT'S A U THOR I Z,A nON (To be ·e"e.;vted only I" c'''""",''·llo" wilh cCi,Se>7 referred '0 Depl./

THE 0 ",,,,,,S'PORT

D CARD OI'"IOENTI'" D ,CEATlFt'CATE

"UTHOR.lr"

W'A~

D' RENE-WED TO --:-- _

D AMENDED · ... ·S· REQVE,STED

o EX T EN DE D TO _

STAPLE ONE PHOTO HERE DO NOT MAR FACE

The pa SSP""' phoros required mu 5' be approxjm.:i.,dy 2;" ·by '2>-)' [nchea in s i ze ; be.en .thin ungla.ed papc r, show lull I,ont ,·jew 01 applicam wi,h a plain, ligh' back,g,ound; and ha ve. been taken wi rhiu 2 )'ea rs 01 ·da,e submi ued, Whe n dependcnrs ate indud.elthey should be ~h<>"'n in n-,.llooup pho,ogr.aph. The consul ""HI not accept photo s that ale no r a goo d JiJ,: .. ne ss , Color photo.graphs are' aceeprabl e;

Dr.. riof slaplf!! sf!!corn/ph%. AUaCb ./005('/)' byprtPii> clip.

O,ATE

.OPiNIOtoi OF CONSULAR OFFICER ;0:

(Co,;sul of Ihe United S-lOf",,' 01 Ame,iea)

x

FOR'" F5.299 7 - 64

In certain case s spe c ,fie aUlno,i""tion by ,he De.pallnlent will be required, In ehese .cases an e ~"a copy ·0 hh" (orm shoul J b.,. prep.aeed. Vpon re ce ip r ofrhe rep anmenr'e £<:1'1), ,he e""a c"'py shouh! be Iranmnined wi!h ,s'QOla'jon 01 ,.h .. ac,-i('>n taken,

DON'T PlUT IT OFF APPLY NOJ

A~OIO THE LAST MINUTE RUSH

'DE? <\iRTME."lT Ii:lF :5TA ::

APFlICATIO'N fOR P,M POR'T B'Y M~IL

~el:lr pr,vieLJs PQ~PQrt i:isue~ wi,th n ~e post eIght y~af'S, two .sIgned ph<ilJoqrophs bnd he f e o,f- $10 MUST (lc~ornpony this oppli~lIQr;.

I

~ 11~

B

c

CfJUNTRJE.5 1'0 BE ¥ISlrED

1-'~&...,j_' __ JC:_.E...£.-..-p""_""'--! [lIO ¥fj~1'1C:CT TO TAj{E ANOTHER TRIP P:l:I'MAD?

[V"" [No IF sa, WITHIN C . ..1 I ~pdr ~ 2, 'fGUr5 I

n

stalaments made kl1owllJ!lly and wliliolly in jlBSSport Bpp!l~aUol1S or aflldsvHS.DI(llher supp0lling {J,o~Ur1enI9 are p~nISJ1lble by fine andlllrimpris nrnali, I ~n~llr.

Is-ions of 18 uSC L~Ol ah~ "or IS UiSC 1~*2. The atleratiOJl lif mullIilUm1'of a easspalf l~s'JJed JlJl!Su~lIllo thts ~l!Qjln1l,l1!lo Is ~untsbaWe.b~ ftQ~ andf()r under 18 USC 1~!l3. The il'se of a~s$Il"rlln '/loJal\oll ~I iJ1e restnel10lls {be-I11ID I~ punJ5~able by n~e afld or ImprlscnmeoL nder IS,US:C l~H.

United Sla!e.s d naturallz.etl as B clttt,Bll 01 a IJlfi!J~O stllte; (allen an o~lg, or made an affll~'~lion 0/ atl'i~riorl]lal Qel:lar~ltlm 01 stle-

tertld I)f served of a Inr{llM slllte; aOllefl!!~ r Ref'lo;med li1e ~Ofies gl any office, p~lt or employme~1 un~gJ \J1e ~ill\eTpmert( 01

I I~ntmctaijort of nalla~all'tM eilhJr In the Wnlt~~ S~llfs ql ~efol~ ~ dlprQmafl~ m ,Mnr tUJalo[fI~8r of tbe Un!fe~

l.mi';",,,j,.I,QI.J;'ua;.;;<..,'uibJ..IJr..tl.lJJJnleOh'9 ofthe natronal!1y oj au¥ 11Irdgtl, slatej OJ:t;~n CQnl)]tlle~ bj, a nlIUrl 01 aourt rnar~l~ Ql 6Jn'IIIp'el.e~t jiJ.rj sQl~l!On Iii

tommHtmg any. illlt of treason against, or al ern~tl"~ ~y ~rl!e to~verll1row, O( pejiliJl1& arm$ ag~lRst Ipa Uml~d Slates, or COfls~i(i~g ID ovatt,l!rol'l, Ilol ~ll:(jln 01 to tI.eslt'-tfy by, arte, the- GQvarnlTltlnl of 1M I;Jni'tea states.

~ If apy ot tho 'eoolJe·mlllltiOrJed nct'S ot e end !lDns have 1)~1!11 p~rl{lIUlei'l b}: III ~PilJ~ lolhe applloM,I'1 tM Bo/lIDn ~Hlab liIj;mUes SIlould HI> slruCk our, and 3 supJ)lelrreqlar~expl,snaldh stale11lenl shlliM,be ~'II~G~e~, s1M~:tI ~lid m~e a Jt'1rt oj !hls a~~lIcatlon.1

OECLAR8TI0N

l.detl~re Uf1deldhe 1l~11~IUI!S of IS(IJSe ltllU an~ 1~2 ,see.y{A:R~Ir>lG, aflO'la\ i.I1allftB"sla1etll1l"nls 11!~~a til thls ~p~llc~tflln are {rue alld com~hl.e Q tile 'besl al my knOWrll!llle an~ a.elleL I fur Ih'et deGlar,e lhB II 'IIfl I support ~n~ oeJ~hd ~ha CpnstitIJlIO!1 of 1I\a U)1lle~ ~tates; a~inst i111 ensrnlesj IOJel.R~ and domesl\ci thai I will bsal twa faith and all'egial1GII 10 Ihll''Sall1s; and t~Bll I~lre tJjlS obl(g~loI11r!l~1 ~ltlIOIJ( mertle! lesarJllllOo-or ese ilf

evasion. r r;

_C'

fOR~.AP pntlYEO

3UOGET I3Uf!E;W 1'l'O, 4",~Ra1""

Il t.,.. '\...
DEPARTMENT OF "STAT=:
REQUEST BY UNITED STA TES NA TIOl'IAL FOR AND REPORT OF
f EXCEPTION TO SECT[O~~ 53.1, TITLE 22 OF THE CODE OF FEDERAL REGULATIONS
t
! REQU'EST
f l h, -: be en Informed that my pas$!"ort IS no t valid and that a valid passport is required by law to enter tb e
1'·" ted _'iwt<;:". I reque s; that an e xceprion be ,g_ranc::d ro me, as provided in Section 53.2(h)., Title 22 of (he Code
I ,I i i- ed e ra l !l.i"g'.l jati:~n., I unde rat.snd zhar la fee of $25 i:; T.e··quire-d under Section 53.2(n) and I wi II rem-it such fee
'" "" p '"~''' t: ",," Department of S"". W"hiog'",. D. c." 20524, ~i thin 3~ d'~: I , _/z
I ~ !/UI_A .,
. l...£ $c1._A:'I?t:l ?.__ArC ./J£-:/\.. 6/ -c:rl . . 't£Y
i /L (S tg tuxture }
t=- - REP ORT - Pursuant to Section 21 5 o~ the Irnmigrution and Nationo I ity Act ·of 1952
.j 1"(; Drre cto r, Passport Qflice
I
[ Dcparrm em 0 f Scare
Washington, D. C. 20524
1 Arrn: PT/AC
SUBJECT _
r
! NAME DESCRlPT10N 516"
I 3T.A~JLEY AtTN S:QETDRO Brown Brm .. -:l
I 13'5 Ib ~
.! HOME AODRESS D_ Taman ~.\atr~.man 22 Pav , , Djakar<.oa, IndonesiO'_ q"~/~
I ' onolulu, 1617 So~~th .Be_etal'!~ ,. ·c/o ,Stanley Dunham) j
. .- I
I NAN~RAL~ZATION DATE --, r
BIRTHO.<l,TE PASS PO RT NO., OAT E AN D P LACE OF IS SUANC E ('
Nov. 29, 1"942 F 7777$8
t":
. B'IRTHPLACE "'-19-65 ~
l~.richi ta, Kans·as Honolurtr; tlar.rre.ii ~
.....,
I DEPARTUR'E FROM UNITED STATES
IDA TE AND PLACE OF OEP)l.RTURE D,ESTINAT I d~i ~
October 1967, rtonolulu, Hawaii Djakarta, Indonesia ~
FLIGHT NUMBER OR VESSEL NAME OF CARRIER - ~
I Je.!=E-U Airlines -._
- \
TRAVEL TO UNITED STATES l-
DATE AND PLACE OF n EP.,I, RTUl'i E FRDM AS·ROAD Ii:IENTIT'f DOCUMENTS PRESENTED l'-'
Oc·tober 20, 19'71 , Djakarta, Indonesia P2..SSPOl"t as shown above ~
I
FLlG·HT NUMBER OR VESSEL NAME OF CARRIER
PAA 812. Pan i'-nerican Air"",'ay..s
r TE 'ND PL>\of OF ENTR' O'EST INATION
RatTa.ii lionolulu, nEl1...raii
I October 21,1971, H-otlolulu.,
ACTION T AKI5N
Identic,Y and citizen ship established.
E:1Cception granr ed under 22 CFR 53.2(h).
I 0Fn"/2 "1 'CI7I
( n$ p~d<>"'s Stgm p)
,
PLACE (.lmmiq'''Hon and NghJrol'2ot;on S .e "'ie~,) SIGNAT UR E ilmm illrot;on Qilie.,r'
EJNDLGLTJ, R.4.HAII i '" __d~~
:kr7L!l.t,d
Ii -;,'A Ilf.~ :r;/~ eJ , _. y ? I
- 7" _.,(. ... - '"C (. t .... L ...... ~.': .. D- ~( (1":\ j .- l ,

DEPARTMEN r OF STATE APPLICATION FOR AMENDMENT OF PASSPORT

__________________ r".:;O:.;.R:;:M::...;;"'r "JVEC -rHJDr,ET Ii11JREAU NO 47,,059 B \Po~"port Ofl'ce Uu Only)

Amend e s .showrr Jr) s ec+icru

DC

~E OF

o

P3

2
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0
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"I. -----------------------------------------------------~

INSTR;UC"tI'GN·S: All re ques t s for inclusion of """9'" rnu>;.'· be s-WQrn to (or affirtn .. d) ".,-

fore an Agent ,j'f the D e "orfment of .Stct e ar Clerk of Cour'. Photo9r<,:ph's, which me e t ,I", requirements belo'Yt end .evidence of. citi:t!!'oship must be 5ubmi..tted for all persons to be inc luded 6y thi 5 cm .. ndmerst , If such .perspns have had, or he"n included in,. " pre-vi- e ·us pc s spee+, it s houl d be $LJbmrtted in~teo:-0;1 of oth,l;!"r do.c1.Jmentsr end Se er le.n G cornprt!lfed~

o Add vis., poqe s ,

. II'

[~:~_{P1

I" Sra ntv A hl7 So p-/oro, 0 ~i.i~en ~,~

~O_I_t_he_._U_n_._te_d_s_I~_t_~_S_,_d_O_h,_j~_,,_b_Y_re_,q_,,_e_S_I_t_h_o_t_m_y __ po_s_s_p_e_r_,, __ W_h_ic_h __ iS __ "'_n_c_lo_S_~_d_,_b_e __ o_m_e_n_d_e_d_c_~ __ ._ ~-lic- __ f 18- r

rlndicated below. '" ~ I~

INCLUDE MY CHILD.(REN), AS FOLLOWS: (Also ecmp lete SecHo" H if child(re'n) acquired -"' (Pnoto re quiremerrt-s 10, indusia,,) 1"

citizen"Ship by naturalization, and hOI"" not ~ad .. pre.vi.",,,. pOS"II-porf.) I % C1

~ ,~

~AME IN FULL PLAC:£ O-F BIRT ... (City, S'<rl~J DATE OF BIRTH STAPLE ONE PHOTO HERE

DO NOT MA~ FACE F 7\

I"t:~

Photos mus, be ONL Y of persons rc 0" in-

~1~:t"~ebYd~il~ :;;::~ mo~npt;O!i:O::r~ P;;,t;; ;

2» inches in 5i'2"; be .on Ihin, ungloz~d ..

paper "'fin 0 plain, I'gnl bockg'round ana ~

have been +ek e n with; n 2- _ye·ar. of dote l:

submitted -. Photo. sh<>~ld be f,ronl vlew, J\1

b ul' nol fu II-I ~ng,t11, and may net be snep- JI ohot, Pol o,oid,1JceI"ote cr film bO,n pdnh. .!! Wf,en more Ihon I p e rs"n i a to be rn"luded, 1 e group photo is re quf re d, Color photos are oo:cl!.ptobl ...

DO NOT STAPLE SECOND PHOTO ATTACH BY PAPER CLIP

'I'

IPLEAS:: PRI'NT NAME IN "U LL'I

(Firs! name) (Middl" nom,,)

-

-I

o

B

IWIFE'S) (HUSB.AND'S) FUL.L. L.EGAl.. NAM,E !"L.ACE OF !;!IRTH (City. State)

~D-A-T~E~O-F-a~I~R~T~H~-----------------------i~D~A~T~E~O~F~M~A~R~R~.IA~G~E~--------------------i

LII -' ~

~~~~~~~~~~~~~~~--~~~~~~--~~

INCLUDE MY (WI FE) (HUSSAN Dl, AS FOLLOWS, (Also compl"h Section H ;·f fwife) ,e

(h"5.ba~dl ocq~lr .e d cili.zenship by n~llJ,ollzofion. and!.Qr Section I iF wi,f .. was pre vi eo s ly 1 married b .. fore March 3, 1931.)

c

D EXCLUDE PERS0NS, AS FOLLOWS:

"

o MY WIFE OMYHUSBANC

o MY CHIL.DREN (Give n"m~(~J.)

WHO ISf ARE

o 'TO AP"l.Y fOR SEPARATE PASS"ORT o NOT TO ACCOMPANY

o

E

CHANGE TO READ IN MARRIED NAME" AS FOLLOWS,

F

CHANGE TO REA;D AS FOLLOWS:

G I'CHIL.O(REN)'SI (WIF1;;'SI [HUSBANO'S) LAST u, S, PASSPORT NUMB ER

IN NAME DF

I U 1'5 SUBMITTED HEREWITI1 o OTHER DISPOSITION (5'01'')

DATE I'SSUE.D

FORM DSP-19 7' 64

(OYER)

H

"
TO BE COMPLETED BY AN kPPliCANT REQUESTING INCLUSION I N "THE PA5sPORT e F A RELATIVE WHO ACQUJR E D CITIZENSHI P
TH RO'UGH NATUR ALI ZA nON
MY IMMIO,,!ATED TO 'ACQIJIR-E0, U. S. CITIZENSHI? THROUGH HIE N,ATURAL.IZATIOI'! OF
THe: u, -$. ON (M""'h. day. 'r<>ad ON IMenth. day, yead
OSiiLF o PARENT o FORM ER flUSBAND
WHO W~S N",TURAL.IZEO 131;:F/;lRE T><E (1'1""", ,,(cQurt) LOCATED IN .(Ciry. Sic'.')
,/'is SHOWN BY TME ACCOMPANYI"'G CErlTIFIC'ATiE Of NATURALIZATION ,No,
0
TO. BE COMPLETED BY AN APPLICANT WHOSE WIFE WAS PREVIOUSLY MARRIED BEFORE MARCH 3,1931., AND WHO IS TO BE INCLUDED
IN P,",SSPORT (If married more thqn fwic:~, set forth f"c:ts In" .... ppl e- m-e-ntoJ st-ot.mel'l1'')
!-lEA ;MAIO~N NAME WAS OAT~ OF P"!EVlOUS MARRIAGE
.'
NAME 0," FORM,ER H.USS'ANO P\.AC,E OF P<.."vIOLl,S MARRIAGE
FORMER H 1J!;'9 AN 0'5 PLACE OF BIRTH M"'R~I~Ge:: WAS T.ERMINArEO 9'" DATE
o O£ATI-t o oiv.O~C5
IN THE ~V€NT OF DEA 1"H OR ACelDEN T N 0,1 FY
NA.·M~ IN F\JL..I.. ..FtELAToIONSI-IIFI !;T~~~T A.C"OFr:ES-S. C1TV, .a-r A.·I ~
1 have not (an d no other person included or to be In clude d W th e pa s sporr aas), SEJke acquiring Unite d States citizenship,
been 11 arurali zed as 'a cl ti z en of a forei gn Stat:e~ taken an oaeh o t made an. a,ffil'lll'tltioD 9T ether formal declaration of allegia:n ce tc a
foreign stare; en cered ot serve-d ill the arme d forces of a foreign star e; acc.epue d or p erforraed the dur ie s of any office, poSt; or em-
ploymenr under che g'o"V<,(Oment of a foreign s sare or political subdivi sion thereof; vQted in a pofitical el ecnion in a foreign scace or
pareicipaced in an election or plebiscite to decerrnin e th,e sovereignty over foreign rerzircry: made a formal reriun ciarion of naricaal-
i~y either in rhe United Scares orbefore a diplomatic er consular offi c.er Qf th.e United Srat e s ill i\ fgrel.gn $[a,te; ever SO:UghT or claim-
ed the bell.efi-ts <ilf the n aricn aJity of :any iot,,'ign state; or be en coa vicred by a. court or COUrt martial of competent j uri sdi cticn of COm-
rniui~g any act of rreasou against, or aHe,mp'ting by farce to o verthro w, or bearinE anns',a.gain'sr, [he Uni te d States, or conspiring to
overthrow, pLl·t dOWIl or to destroy by' force, the Government of the United Scare s;
(If allY o] the Ii b(JV~ -m'efl-tione d I' ~ ~s 01 .f; on.di ti On 5 ha. ce b'e;"n pujo,me.ri by or apply to the o{ipl!c"n!, or Jo a'a,. o tb er p ers on: in=
ei .. de d 0' 10 be ,,,elu.ded in the pa.ssport, ~h." p.ortio n whi<;h oppUes s ho-utl£ p e {i tru.c" 0 r.tl" and a su.pp te'me',,"~lIttr eXIlI"nato''Y statement
under oath ( or affirmatiorl; by the ""rgo.n I" Whom ill" porli"" is appli.cable sh--oultl be au .. .,fo"d and, made a pant of this applicaeion.)
I sol ernnly swear {afurtn) thar rue statements b.t:r,,-in made are crue and rhar I have n ot previously asked to have rhe se addi-
rional per son s induded in my pas.sporr; tha cthey are !lOC nOW in possession d f vali d p assporr s, and tha,'t they have not made app li-
cation for p as.sports and been refuse d,
><' ~ I~ ~ Ltr
~/ ~_/7~ ~'. __ . ____ ~,
, " (S'gmH,tl.re of Appii,oant)
-: I

J

K

Subset/bed and .swo rn [0 (affirmed) before me tins -----",_day of , 19 _

J

! A g'e1'cl. D "pac1m.era "-I S ~'H~ Q r Clerk oj CQ uri)

L ~

FORM' DSP .19 7 - 54

A

, (Pt.EAS,E PRj!'!! OR TYPE- PENCIL NOT ACCEPTABt.Ej - r 1 For Department Decision
.. - ,
DEFAR'TMENT OF 51'ATE PC;7 LGICATIQN Jakarta, Indonesia
APPUCA nON FOR !.RlPASSPORT o REGJSTRA TION ,oO.5T A€TION REGISTRATI,ClN APP~OVECP 4
PA 5SPORT ISS,;JE::J
~mill,,'e ALL .. nfd~ .. i", 01) ;;",,1[on5 t.ho' opp.ly to y<>u. if lnlermutlen is N'o. Z2433100 O·ot.
unknown, .. ,H .. " Unknolin'. Do nOf I .. ave ~Ionk .,,00;,<15. Use Qd'~itionQ I June 2;1976
sheeh whet" spcce provided is !)ot gd<>quofe. 'DI:IH! Exp,jI'~S-
E'Pir.;Tune 1,1981
TO BE COMPLETED BY ALL APPUCMm CI.lRD 0 ~ IOEI'HITY AND REG.

(First name) (Middle name) (Last name) gsa ApplTc:cflon fee :::o"~ct.d No.
- /;
y /-'A/'H -1,-(-1 [lA'm F •• "ollecte~ /1.;..):.$ D.[Jt;e
STAN LE.:"1 AN AJ Sa lE.raZ~, a cttlzsn ONe F_ .",,,spor, J/, ·,·f 0$3 fee call.e'ed. (10, "",dl
I o Offichtl ce e.s ccrt o 4-8 -peg 0 PC'!!i P crt
of the llnlted states, do hereby apply for (a passporL) jteg_ls(falilin)
DA IE rJF BIRTH "LACE O'F BIRTH lCi'!, .tD·T~/plovi"c", <o.untryl M'(- LAST PAs-sPORT 'liAS OBTAINED FROM
M;jh 12,1 ~2 (Note: !f ini;t\i~9d in o~,Qther"5" pus-sport, stohl rUl{ntt of- he:~t4t)
WIC. H ITA 1 ~A NSAS J lI'S,1 l.ocIQt[Q,n -oj rS.I!io'uin$l .Offic'!l'" O{]'fi! of l s-sveeee
HEIGHT . .; I COLOR OF HAIR IfOLOR OF EYE; SI'lCIALSECIJRITY NO. I/ON ",L I..Jt V ~t).Aj o/J 11)-<
,t"~ut) (5141 c",) Wl ~JS .. ~O .. ,.s:z: .J. .,
.5_ Ft"SiI". :tuJWN I.a 'M ~u .. b.,: C,' 0 ~U)CI{ t- Bl:lar-tu': ~~
VisiBLE DISTING'U ISHING MARKS .OCCLJPA TioN ,~,t14D. o $ubmirrQ,d heu'ewfrh
~ Ca"~o!!'lle-d i:irJId rl!l!tvrrJ!!!& [_] Q..rft!![ dtsPQ,.-'iHoll (:HQ-l~)
NONE. STtJ.e~T -S-een and raJ!Jrn~d
NOW R.E,I DI NG AT tiI,-l.. "fA ",.., ROM' I '-:13 M'r' l!lST ~E'GISTRATWN AS A CITIZEN
";,,;rzN' DA.L A /;1. ~A t'. A 2TA OF THE UNr;>,ED STATES WAS APPROVED
;r:j,EN,:SIOi!eE:':AN;A'~"Wo'3tJLI~;mHj;;;'JI, L CI'!:Ci'! LCIl or 1'{1!!!di'.:st'~"'fn; Offi ee OQtlt ai Regi :=i'trc rfon
I 'SfANUYEA tli iU~!;;AT;'°lF A~;·~n ;~I~tTi,lj1~'~IiCEZ$MN IA JJ lObS ,., DAbLtJLJlJ W.
HAVE VOl) !EVER BEEN REFUSED A PA$£I'ORT 'OR R'E(TI5TRAT~N A~ A CITIZEN OF TH,E ,UNITED STATEs.l oy" ~ ZIP 'f{/lF'J
IF ANSWER IS "YES". EXp("1,11>! WHEN ANI'J WHY
TO BE COMPLETED BY AN APPLICANT WHO £~GAME A CITIZEN THROUGH NATURALIZATION
I IMMIGRATED TO THE U.S. I RESIDED TOONTINUOUS,LY IN TH~ U.S. NATURA LlZATION 'CERTIFICAT E NO.
(M"'~th, yeorl F',om (,Yeo,) To (Yoo'l d S~b~Hhtd h_I!H'e'oVj~A
o Seen end rBftJTneo
o Prm.'v leus I)': .5 ubm-rhed
PLACENATURALIZEO {C;'y, .lol~1 NATURALIZATION. OOUR'T D'ATE NATUR A l,.1 ZE 0
COIilPLETEONLY IF OTHERS ARE 1'0 BE INCLUDED IN P'ASSPORT OR RE-GlSTRATION ANO SlJflMIT G·ROUP PHOTOGRAPH I
(WIFE'SI (HUSBANO'SI FULL LEGAL NIIME ! D~ATIVE BORN I NATURALIZATIO~I1'ERTI FIC.ATE NO. j
. 0 N~TURAL~Z:;:D 0 S~<>;I and ,",,","ot
PLACE Nil T,URALlZED (City, ~.at.) NATl) RAlJZATION CDU sr DATE NA:rURALfZED
IWtFeS) (HUSSA'ND'S) PLACE OF BIRTH (CHy, ·SlOt. or p."·vtnc,,. Co~nt'yJ gATE O,F a.rRTH (Mo., Day. y"",)
- ~ _.- -
NAME IN FULL OF CHILD REON. INC,LUD ED P LI\C6 OF 61 RTH (City, ... rel'.rovT~<., caOn',Y) DATE OF BIRTH R·ESrDED IN U.S, IFrom-To)
/Monlh. day. ~.o')
- ..
EV[OEHCE OF PRfOR DOCUMENTATION OF ABOVE-HAMED PERSONS TO BE INCLUDEI;l (For completion by Consular Office}
Co!,NcELE D OF! DATE OF· 'REGfSTRA- LOCATION OF
NAMES PASS80RT NO. DATE OF ISSVE OTHER. TION OR
Ot:SpaS;1'l'ION BIRTH REPORT OFFICE

OTHER EVIDENCE t;lF U.S,CljIZ~NSHIP PR'ES.~NTED (Soto'. ~i.p<o.rt!,a~)
,
-
- -. B

c

D

E

(OVER - yOU MUST COO1PL-ETE PA'GE 2l

FiORM FS-176

F

P'ATE I'IA'i'URAL iZEOO

PATHE'-~'S PLACE OF' BIR'i,H ~Cit7'1 5t~r'!!!:, ?'fo v jnee 'Q-r I:!lt.r"i~r'

WiG H IrA I(A,NSAS

FATHER'S DATE OF,BIRTH lit 0 F'ATHERDECE;liSED

,lit A,e II a,3 I , f rJ t! F,ArHER .f<ESIPIf'lG AT

P-LACE NATURALI1.ED(Cily, .to")

-Anli:;,~ RES,loED IN U.'_

Prom jJllfi

M.DTHER'~ MAIDE"N NAME

M,,"ELYII

DA TE f'lA rURALIZED-

M.Q.THER RESIDED. IN U.S.

Fr<>m forR 1/1 Te ftrG5£47

MOTHER'S DATE OF BIRTH 0 MOTI-1E~ DECEASE!)

OCT, ~f11 '9l2. -~DJHER ~~IOINCl AT

G 0 I WA~ NEVER MARRI!:O

tSl.l 'liAS LAST MMRIEO ON (001.] M

I LJ HUSilAND DR WIFE IS U.S. CITIZEN US6AND OR WIFE IS NOT U.S. C I,TIZEN

~ ~ W~'~

~ 9~ , (-t;:::"" "'c<l J t::.:

NAMe. OF SHIP OR AIRLINE ..r: .. A~~;_-J~~~ W,··

-~N Ar IYf ' ~~ .~(i~' ::-..'!ff~·"'~'t·· .'~" ~C/Ji, ,:':

r 1 '\f)"t ... ~~ L:,-: ~~ ..... ~~ ~ ~~ --fA', ~

J WARNING: false statements made knoWingly and willfull,Y in passport applications orin affidavits or ot~er 5upportiiJg uoculT\ems sumnneo mereWltll are punl~flaore uy line anD lor imprisoflm~nt under the provisions of 18 USC LOOI anq/or 18 USC 1542. AlteratiQn or mutilation of a pass~ort issued pursuant to thl~ application is punishable by fine and/or lmprlsonmef)l under The provlstons of 18 USC 1543. The use of a passport in Violation of the restrictions contained tllerein or of lIIe passport regula. lions- is pUnishable by fine and/or imprisonment under 18 USC 1544.

I have not (and no other person included in thea~plication has), since acqUiring United States cltlzenship, been naturalized as a citizen of a foreign state;.taken an oatnor ade an affirmation or allier formal declar~1ion of allegiance- to a fOfei~n state; entered or served in the armed forces of a foreiW1 state; accepted ar performed lhe duties of ny office, post, or employment uneer the gove(nmenl of a foreign stale or political subdivision thereof; made a farmal renunciation af nationality either in the lJnlte.d states f belore a diplomatic or consular officer of 1M United States jn a foreign slate; ever sought hr claimed the benefits of the naticnallty of any faleigil state; Of been convfated bya court or court martial of comp'etent jurisdiction or cammitting any act of treason agains,~ or attempting by terce to Dverthrow; or bearing arms against, the United Slates, r conspiring 10 avsrt·hrow, put down or to destlOJ by force, tire Gavetnmeot of the Unit~ ,states.

If ""I' 0', fhe above-mentioned ""'SO" corodN;ons hove t,"en perfomled by,,, qoply 1," If,e OJPPficant, ""0 on>, otne .• person '0 be ini::l.ud"q it;' th .. po,"'porl ", i"l)islro'li"n, 11, .. · . "'ion whidJ applies "hpulrl 6e '-'rock <>vi, rmrl a suppl_"",ory explCX)atory ,,10''''''..,/ unci"" oalM Co, <rfflrmal.lonl by ,he perso~ 10 wi>;>m ,Ile- porl'on is <f>pllo:clbl" sl-rwl<i

afro",""" a.rI,.;od" a pari of Ihi's cppllcafioo.) ,

i soliimnly swear (or affirm) that the statements made on all the,pages of thisapp!icaUon are true and lIIal the photogfaph attached is a likeness of me and of those persons

lobe Inc luded In tile passport. .

(Seal)

lv

~

Oonsul of 1M United States at --=J""a=ko;;, :.=a:,_:r,_t=a,_"",I"",n=d:._:o""n"".::e:,,:s::..' ~=' .:::a'-- _

IDENTIFYING DODUME/'ITS S.UllMITTBD (S~e 8 FAM 243. f'rd,,~durc.)

"

J

PPL10ATIO", FOR ~ PASSPORT 0 REGISTRATIO POST LOCATION_-:::...J3.k::;::-=3.::o_rca.';:;· :::.L,-_;":::·!1:!!d:!!:0:::t.n.!:.:."":;_:s~i:..2""~- -

____________________________________________ ~~~~~~~ POSTAGTION:

L entf'ies in all sections that apply to y:ou. If inhumation Is unknown. PASS PO RT ISS 0E'O

-~·L'nkno1Nn... Do not I.". 111i11n1c lJIBees. UMilddi!ianal ~Wf\erll space No. _~:3 0 J 72 21

",av·ided is ncudeql,la1e. PAINT OR TYPE ENTRIES. 4/21</81

t---------------- __ ------, ----------1 Data _--=:.L...::':"'::.!....=:"""'_ Expires'- _

J;------c--__.!.~~~~~~~~~~~~~~~!..----------1 EXPiresi_....:4;.!,./....:2:....7.:...:/_J8.::.' .::.6- __ CARD OF IDENTITY ANP REG.

(F;frt name) (Mjtldle name) IL-ast n_,"",a) 19 $3 Appllcat1-on feo No. _

collected

f9 $10 Feo.a coll~cted o~" --------

o No F-ee passport- D $-5 fEl" cQllec1:ad (for card)

o o fflchl I pam;PQ'~ 0 48-p~ge D 96-page. p""'SD()r't!l

REG 1ST RAT 10 N APPROVeO

Date _

STANLEY

ANN

DUNHAM

BROWN

535-40-8522

D Cernfic3t.e of N.atural1zafion or Cftlzenship

Datil:"" I-:l.{l ~

Bea(er'~ N"rne,_ ~~ 0 Submitted HereWith No.: L 2-'t-.:s~ 100 r;yCancaled 8. RBturned

Place: ~ 0 See", & Returned

LOR OF HAIR (Spa'" out}

Baru

MY LAST R'EGISTJ'lATION AS A CITIZEN OF THE UNITEO STATES WAS APPFlOVEI3l

Location of R-eglS'terlng .

NB _0 F THIS APPL lS;:A

li>I ........... OEO IN A U.S. P.4\SSPORT? llZI Yes 0 No .

IF UNABLE TO SUBMIT, M(;)Si FleCENT PASSPORT STATE ITS

No.: Z2433100 Issue Dam. 2 1

00 NOT IMPRESS SEAL ON PHOTOGR)'Io.PHS.

BIRTH DATEIS) CH1LD(RE.N (MO., Day, y..-.)

o Submitted H"r:9Wlth

o Canceled & Returned

o Seen & F'lP'1;urntfd

Pho~. mUst b .. ONLY of Per.loqs to be·lnclud&d (other than f)IISSPOrt bearer.). When more men one p.,,:;on is to ba included, a grou:p photograph of me IncttlJllons [s reqUired.

OATE (Mo .. Oav.

CHII..O(RE'N)'S NAMEl$.j IN FUkL.

CONSULAT.e WILL STAPLE PHOTO OF INCLUSIONS HERE.

o Submifted Herewith

o Canceled &. Fhtl,lrned D Sea" & Returnlld

I have not ('and r,~ other persol\\ InCllude-d in this appllcatlon has), $i'n~ acquiring United Shtu-.;:ltI~anshlp, performed any of the acts listed In on me revetse of this appffoad.on fo,.-,,> (unl.ess explanBto-ry statemen~ is att'acfled). I solemnly swear _(0' ~f1irml thet the s,(atemennl made an all of ~he pa9Bs of this a~plicnion are ,rue and thaphotogr.aph(s) ~'cfled .$ (are) a likeness of rne-and}5f tflose;.~a!'$ons to be ill .. 'jded Inthe./8ssport.

'- - ... ~ "/

(SEAL) - '- . - J 'I ' > ;.~./., ,=

{To bI! si9ned at sam .. tjlTlfj by hysband/wife to be inclUded in panportJ (To be .ignad ·by Appl;c~nt fr'l presence of person adml"r.t<orlng ami)

OPTIO.NAL FORM 178 (FORMERLY Fs.t7S1

PAGE

-1;

TO Be COMPLETED BY AN APPLICANT WHO BeCAMe A ~iTIZE~ THROUGH NATURALIZATION

I 1MMIGRATro TQ THE U,S. (Month, year:)

I RESlD·ED CO'NT'INu0\JSL Y IN TH.E

U,S. F~m, (Year) To (Yea"

NATVRALIZATI6N CEflTIFICATE 'NO. o Subm med herewIth

0- Seen and returned

o Pr"vtpu~fy submitted

P!..ACE NATURAl.,IZ·EO (City, state)

NATURALIZATION COURT

IDAH: NAIURALIZ~D

o

TO BE C_OMPLETED BY ALI. APPLICANTS

VISJSLE DISTINGUISHING MARKS

OCCUP.ATION

PROGRAM OFFICER. FORD FOUNDATION

none

It \llDAEN ~T CG'.1PLETE FOLLOWING l.f CHILDREJ\I OF A,PREVIOlS MARRIAGE ABE IN::LUOeD ciA IF PREVIOI:,6t..Y MARRIED BEfORE- MARCH.J, 1B3~

I WAS P!'IEV'IOI)SLY MARRIED ON TO (Fult I~gal nam",) IWHO INA$; BOFlN AT '(City. 5t_. Countcry)

ON (Da'ta of birth) 0 FORMER HUSBAND WAS U.S. CITIZEN IPAEV10US'MARRIAGE TERMIN'ATED BY D,DEATH D DIVOACI o FORMER HUS~ANO WAS NOT U.S. CITIZEN!ON .(Oate)

aJlVPLETE IE' AR'UCANT 00 ANY P'ERSilN 1IICUJD$'IN SECTKJN B WPS III:1T BORN iN THE I,.INIT'EP STATES AND C~ CfTlZENSHIP l1-AXJGH PARENT~ EN,TEIllED TH£ U.S. (Monthl (Yea" IF FATHER NATVl'rA.LI.Z,ED: IF KNOWN. FATHER;SAESIDEri<C~ ~------------r--:----:----------I PHY.SICAL ~flES'ENCE IN U.S.

Dat~ Cen:iiT~ate No.

o Applicat:lct

o V\Ilfe

From rVea.)

To IYur)

From IYearl

Tb IY"ari

o Husband DChnd

Before (Name of Coun)

RESi OENCE/CONTfN UOUS PHYSICAL IF MOTHE A NATUAAuZEIlI: IF KNOv.,t.l. MOTHER'S FlESloeNCE

PRESENCE ~N U.S. FromlYearl To I'Y .. "r) 1---------------.---:----:----------1 PHYSICAL PRESENCE IN U.S.

elite Carti-fica1:e N9.

o Applicant

DWlfe r

QHUSb,md ~

D'phlld L

Place (City. S'tatel

S.e.TOre (Name Cif 'Cou I't)

G~l~~~~~~~~~~~~I~~~~~p~R~O~PO~sE~D~·~T~R~A~VE~·~L~p~~~'=S~(~~~m~M~a~n=~~m=.~~~I __

( INTENb TO CO,NTINUE TO RESIDE _ABROAD F'OR THE FOt.i.awlN.G PERIOe AND PURPOSE

Two years contract with Ford Foundation from January 1981 - December 1982.

Ill\lTENO-1'0 RETURN TO THE UNIT.eO STATES PERMANEI\IT:t:.y

? \ RESIDE WITHIN YE,ARS II/IONTHS

QAT,!: OF Oe.PARTURE

H j '\ PRIVACY ACT STATEMENT

~~------------------~r_---------------------------------------------------------------------

T~e ioforma1.ior:l S'olici1ed <;In ,his f:t~. i_sauthor1z;ed by, bu~ nOl.'imited 10;" th.ose ~tlnute5 ,cod.fled ill Titles 8. 18, ~nd i22. Unillld Stltas:COda, ~d 1111

predec ... so~ s,atIJ~ whether Or not \:odltl~d, and a'il. reglilatrons Issuad PUf';U1I1'It to e:xecutl~a Order 11295Qf A,u.gust 5, 1966. The primary purpose tor '.ollcitlng the infQrmation Is tOil!sablish citizenship, ,rden,tity and entitlemen1 to Iss-uanca oi II Unlfud States Passport Or relat.,:j facility, end to properly

admin~ster "nd enforce th ... hWvs pert"ining thereto. -

The informatfcm is made avail'abla as a routine use on a need-to.k,now o~l~ 1:0 personnel of tl1e Oep!lrtment of StatS and other gov81'nmentillsenclei hwinl(ll statutory or other ISMur aU1:h"'rlty to malntain ouch: irl'filrmatjon In the perform anQ-EI·' OT Ihe.ir official. duties; pUl'SUan1: to .'$..IOpoen, Or cOurt ord"r: and, 5 set forth in Pa.rt·t;ia, Tlt!e ;li1!, Code of Feo;leral Regulatior.l!dSee Federal F!'egi5fer Volume 40, pages 45755. 45756,47419 lind 47420).

Fatlur!! to prOliide the irtformlltlof.! .equested On this form m~y result In th_e denial of a Unitad Stilt .. , Pmsport, ..,tated documen't or .. rvlc:. to the indlvldu.1 ,"k'ing ~u(;h pIIs:opon, document or servTQe.

NOTE: Tbe di$Olo,uri!! o·f VOl.lr Sooial S",curily Numbe" 0, of the Identity and 10o;-atiQn of a per.;pn to bit n01jfied In th~ avent of d .. ih or Kcldent i. _n'tinily volu ntarv~ I"IOw.8II8r, fail ... r .. to p I'Ov:;de thl s . infQrmatlon may pr8llelll the. Oepanmen_t of S tat. from prOll iding you with tlmelll 851f!itl!nc. or pr01Botion In thEi even,t you shoule! encoun,,,r -an emergency situaT'''' whl1" outside the U nr:re.d-Statl!s'.

ACTS OR CONDITIONS

1M "'1' of the balow.mentioned ,;,cu Or eondhion. have been perfor'med bl' or $pply 'to the applicant, or to any o1her person to be 'Inoluded In the p'asSport. the ponton Which applies .hould ~ $tTl.lck QUt;. lind a supplementary a}<Plana'tory s'tat;emen"t under oath (or IIffirmatiQn) by th" person to whom the. pod:ion is .appllcable'should be atia~hed and mad,e a part of -this IIPplicatiDrd

I have nOt· (and no other IJi'rwn included in this 9Ppllc3t:ion has), 5i'nee aoqulring Unite·p St-aties crtizenshlP, been naturali1ltJ;l •• a oltl;l"n of a foreign state; taken .. n 93th or mad .• al') affirmation o. other fonmd decl"ration ,of allegi"".:e to "fo.elgn ~1;e; entered or'SQrved in 1:he lII'mecl forc •• of • for81(Jn sw'tel accepted or performed cthe duties of any office. PP!:t, or emplo'lment ~nder the government of a foreign nate or polTticil! lubdivl.r')n d1ere<>fj made. formal renunciation 'of national'ity either in the United S'~atas, or before a qipfom~t;.; or ~O'n5Vlar offjcer of -me' United St<l1:l3.1 in 8 foreign Sta'tlti ever .0000ght .0' cll!!meej, the benefits of the nation aJity o-tany for"8lgn state, Qr been conVicted by a cOU rt or COU rt martlel of competent j.,.'iS(jiattOI} of comm irtjng any ac:t of treason again.", Or "'!;tempting by force- t.o Overth(Ow, o r bearing .... ms· against, Vle U nfted States, or conspiring to overthroW, put dOWn er to destroy bl' fo(ce, tile Government of the United States.

....... A RNING: False $ta~ements made Ic'nQvvingry and wjitfl.lliv 1;' paS$pon: applications or in aff;davj~ OF other support;n.!! documllntl!l Ivbml't1ad "therewith lII'e p~nhhilblB by fine -eM/or i1T1P.rlsonmant 'Under the prOlli~iOr\:i of 18 USC 1001 8n~Qr 18 USC, 542. Alteration or mutihrt)on of • PII$SPOI't InueCl pursuant to· th is applkation i.' pu niShab Ie bl' fine and'h'" Tmpr.isonment ,u "d"r the 'provisions of 18 USC 1543. "h. use .of' -a passport in v'idlatlQn ot the restrictfon_.5 contai~d therein Or Of the ,passpor't <egul-atioo,; is punishable by fine end/or imp'risor'lment under 18 USC 1544. A II stateme<\t. 'and docu-m..nu s:tJpmiUed are·sul;lj e cr lo'verinc;atic,;.n.

IFOR USE OF OFFICE TAKING APPLICATION}

I DENTI F Y ING DOCUMENT(S) OF WIFE/HUSBAND TO BE INCLuoeo INPAS.SPORT

O CertfficlIte of Na-t\lral-

iZijijon or Ci.tlzenship No.:

o P~pon I-sslJe D"ta;

D Oriver's LIcense Place of l$!iue:

Ali'p LI CANT'S I DENT /,FYI NG D-OCUMSNT(S')

O CertifiC!a1:B of Na,.u!<ll· Iz"tion or Cltizen,ship

lJ PaSSPOrT

o DrIvers License

o rytl'ler (SS;;"'cifyj:

No.:

tssu 9 D'nE:

Plac!' of Issue: fSsued iii Name of;

Issued in Name of:

UNITED STATES DEPARTMENT 0 5T ..... TE

APPLICATION F ASSPORT BY MAil

1":'11111r'11~1IcRr'II:I/"'~ON5 ON BACK OF FORM PRINT IN INK IN WHITE AREAS a l ~

o 0 ~i 0

ODe t!

IDENTIFYING INFORMA nON NAME /

'FIRST MIDDLE SrT}N ~y / f) IV

Pv N rJ~)./J

ST

MOl!?; HE~

5"16

-'JIlt Inches

COLOR OF HAIR

,8l<.oWN

MOST RECENT PASSPORT ISSUED WITHIN PAST 8

N

I I

R 3~G 155268

I

dJI{LI f ;\~::, l. i A ,f rlL 't

'- _. - - - - - -- - - - -. - - --"

,,0 I

lssue Dale

Erldomment.._____;:==----_-=-_

~~I;B;~

Month D1JY Yeal

HOME PHONE

J>lolg.111'11~i'i41511

IArea Cod'll

SOCIAL SeCURIT"v NUMBEI

~r> !>I Y"t01 &15i.;(,;;

rNot Mandatory I

BUSINESS PHONE

I I I I r I

IArea Code I

COLOR OF E'lES

I3ROWN

ISSUE DATE

11 ~ i11

.... """. .. Month Day Year

e,.,rll• <!.A

!§~~et City Slate, ZIP Codel .

5T ~A-I'I Lf 0 ~ fiO I\J o: {.J~ (.) / 11-1

OCCUPATION

CO,NS t.J L rltNt

DEPARTURE DATE

......... 'I"

I

[I

,

I

PHONE NUMBER

PROPOSED TRA VEL PLANS AND EMERGENCY ADDRESS INol Maodatoryl

LENGTH OF STAY

I W£F£J:::.

COUNTRIES TO BE VISITED

?IIILI PPIAJE S

PERSON TO NOTIFY IN CASE OF EMERGENCY IN01 Traveling 'Mlh YOUI

NAME IN FUU

ADDRESS

STANLEY' ANN /"7 s-,. BElf!.eTr1/VI/T ~ OI~lql~9121Ji I J 7

MrJlJ£LY/V puttJl!rr-t #Ioog

AElA nONSHIP ~IJ I!!£ N 7.s.

OATH AND SIGNATURE IIfanyof tnebelow·mentianl!da.:m0' condltlo1ll!hwebe.!n perfortnedbyol p1y~o theappU eam, {till par-Jon w ch IIe5 ~hould be Hnw out. and a 5UpplemelIIary e~planatorv 5llJ11Im'!nt should be DI'bIChl!d, signed and mild .. pllr 01 th!5 applJ~ofl.l

I h!Jlle not, tinca acquiring United SlIIt.i!S eitmmllhlp, be.:n MtUmlued '" a ciderr 01 d faf~n state, taken an oath, 01 made an alf",m8 000 or other fo<mal decLnnrtlon of alleglan~ 10 H foreign stil1.8; eMurQd Of rved in 'he armed fotC45 01 a forelgn 51llUt: Ilccepte.d e pMfQfmlltl I e dutjw of IInv office, 0$1., Of flmpfovmiifll urldsr the GO\lernm 01 Qf a fo!~lgn stale or polllical5UbdMslO"n merllOf: mad a formall1!1luncilltiofl of nationality either in 11111 Unil1,d States 01 before" diolomlUic Of coosu r officer or the United Stoles·1t a fol1llgl • - SllIte. Or be n oorMCled by II eeun Of toon mart",1 at" compe t jUrisdlCEio" of committing nyoct of treason agl11nll. Or lItll!mptm9 bv 10rtIe 0 overmrow, 0{ bmtring II,"", agl!!irnrt 1h

UnitRd" S~, Or conspifin; to O\Iertl'u'cw, pin down Or demroy by force Ih Govvrnnwnl of tho UnltMI Slates.

WARNING: FalSll mr.emems made know\nlll~ and • ...nIMly In passPOI1 <lJ;lplrr:.a11cn~ cr .affJd8'/lls O( QItI_ &Upportln9 dOCUmll!'1!1I ara PlJrusl1nbla by firm an..Jlo, ImpI~nmaut undlll It! prolllslons of 18 USC 1001 alld/Of 18 USC 1542 Till! alnntion or mutilation at a P,HI$1:1n Issued pursuartt <0 thls i!IppHcaOOn Is pun ~e bV Ilntl andior imprisonmenl under 18 USC 1M3 Th U&8 01 a passport ,n "ioilltion of III restrk1lOl\~ .,,_,,1 '" punishable by fin and, or imprisollmerlf .md r 18 USC 1544

DECLARATION! I declare thai lhe stawmene; rna . In lh~ .ppll ptll:1Il are we and cemp e 10 t.II1l best of my knowtudye !ind ~filf In", Ihe attached phOlogl1lphs 111 ~ lI'ue Uk ,nes

01 me. and thaI I haw nOt been IU1J d or inchu:li!d In a passport IrL5UOO s.ubs.eqx,,~~ '"; W'~_ ':L f?J ~

/( fo1~;Z111lfo . ~

fOLLOW INSTRUCTIONS CAREFULLY-INCOMPLETE OR UNACCEPTABLE APPlICAnONS WILL ElAV THE ISSUANCE OF YOUR PASSPORT

FOR 9SSPORT SERVICES USE ONLY RECORD: Tv" 01

121' Passport 0 Evidmnre QI Nam~ Change

Baara,'s Nama. ~ 1 e.J

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