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AUG-31-1994 14:39 FROM r UNIT - TO @ WMFO P.14 17 YOURRELATIVES Give full names and enter ine corect code for all relatives, living or dead; specified below: 1 + Mother (first) 4 - Stepfather 7 « Stepchild “19 + Stepbrother 123 - Half-sister 16 - Guardian 2 - Fathor (second) 5 - Foster parent 8- Brother 11 - Stepsister 14 - Father-inlaw-~ 3 - Stepmother 6 - Child (adopted also) 9 - Sister 12. Half-brother 18 - Mother-in-law Countey ° rut Namo f deceased, chack box on the left ot Date of Girth mmCounITy OF | Current Stroot A iy tat before entering name) | coe Month/Day/Year country ot Bian Citizenalip {eountry) of Living Relstives | Stat ee Cee ae a (SI penmry A.Mikva op) 2/25/1893| Ukraine | U.S. y | = oI “ —hasey Mee para PE las % Made De tise | 3725705 | wee 18 YOUR MARITAL STATUS Mark one of the following boxes to show your current marital status: 1 - Never married (go to question 19) se 2 - Married Current Spouse Complete the Tollowng about your current spouse. } CY ce ea ge CET a RN OO PTO SOLS LE 2 re ee Ch eal Security Numbe b6 ountry of Gidzenship Wate Married a i If Separated, Date of Separation (Mo/Day/¥r) if Legality Separated, Wherg ePremenntocatod? City (Counity} tale Address of Current Spouse (Sireel, Gily, and country if outside te U.S) : r\* ya State dP Coden = SOE ae Former Spouse(s) Complete the tollewing about your former spouse(s), use Dlark sheets if needed. — o, ‘ 40, CUNY quiside the Ue) . °, | Stare z Suny oF Cinzenship 7 Date Married Mince Maree Re si Oulse I rs; tale Bok One, Then Give Date t MontvDay/Year Divorced, Where if ihe ecard Located? Giy (County) tae Divorced || Wiktowvedd adress of Former Spouse (Syver, aly, and country i outside he U.S.) ~~ te dle Gode - PERSONS LIVING WITH YOU Does the citizen of another country, or a United States citizen by other than birth, live at your residence? if “Yes,” provide the information required below. ff a United States citizen by other than birth fives with you, show both “United States” and prior country of citizenship below. aor dist your SPOUSE or r ether relatives you provided in question 7 17. WE eeID Name of Person “Country of Citizenship — “Relationship J i et lh race se nig COMevVSeS Fart 1 Of this form, Iyou Nave used Page &, COMLMUAION SMCSIs, Of DIANK sMeds io = oo re _ comp rete any of the questions in Part +, give the number for those questions i in he space p the right No.1 5 Enter your Social Security Number before going to the. next page » | Z | “| l | -| Ld | ae AUG 31 'S4 12:19 ; 202 324 1973 PAGE.a16