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Serial Removal Charge Our © 4-21 (Rev. 2-11-65) < ) ( C) INSTRUCTIONS: This form ts to be removed from file by a Filing Unit employee only upon the return of the Item. VEAYNay Date of Mail (} Incoming letter ([) Outgoing letter [) Memorandum [} Airtel £2 Teletype [[j Enclosure (describe) ie Lahberatory Work Sheet {_) Pereonne! Security Questionnaire (PSQ) ____ ESSA [LJ Leyalty Form [[) Other (describe) Removed by Date of Removal! 3 D7b /—6 ( For copying (If for another agency, list agency and date of request.) {_} To send to CO To attach to (CD For office use (C) For change to another file ore (Specify) D— [$2L3-/5697 Complete File and Serial Number