SECTION III - FINANCIAL STATUS
1. ARE YOU NOW IN RECEIPT OF INCOME OF $50.00 OR MORE PER MONTH FROM ANY SOURCE? YES NO
IF YOUR ANSWER IS "YES" TO THE ABOVE, STATE SOURCES OF OTHER INCOME

2. SAVINGS INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS
NAME OF BANK, ETC. Monmouth County National Bank
ADDRESS (City, State, Country) Long Branch, New Jersey

3. HAVE YOU EVER BEEN SEEN OR PETITIONED FOR BANKRUPTCY? YES NO
IF YOUR ANSWER IS "YES" TO THE ABOVE, GIVE PARTICULARS, INCLUDING COURT AND DATES

4. GIVE THREE CREDIT REFERENCES IN THE UNITED STATES
NAME Eugene Arnon
ADDRESS (No., Street, City, State) 22, Community Drive, West Long Branch
NAME Abraham E. Waldman
ADDRESS (No., Street, City, State) 235 Albert Pl., Elberon, N. J.

5. DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT, FEDERAL OR IN CONNECTION WITH A CITY OR STATE SERVICE? YES NO
IF YOUR ANSWER IS "YES" TO THE ABOVE QUESTION, GIVE COMPLETE DETAILS

6. DO YOU HAVE ANY INTEREST IN ANY BUSINESS, CORPORATION, OR PARTNERSHIP? YES NO
IF YOUR ANSWER IS "YES" TO THE ABOVE QUESTION, GIVE COMPLETE DETAILS

SECTION IV - MARITAL STATUS
1. MARITAL STATUS (Single, Married, Widowed, Separated, Divorced) SPECIFY: Married
2. DATE OF MARRIAGE: August 14, 1949
PLACE OF MARRIAGE: Rose W., 1932, Eugenie Volsova, divorce, no children

3. WIFE, HUSBAND: If you have been married more than once - indicate number of marriages - use a separate sheet for former wife or husband (give data requested below for all previous marriages). If marriage complicated, fill in appropriate information for future marriage.
NAME Bella
MAIDEN NAME Selia Kirschner
DATE OF BIRTH April 28, 1933
PLACE OF BIRTH Long Branch, New Jersey
ADDRESS 260 Marshall Court, Long Branch, New Jersey
DATE OF DEATH
PLACE OF DEATH

4. CITIZENSHIP: U.S.A.
DATE OF BIRTH 1927
PLACE OF BIRTH Tosashuk, Poland

SECTION VII CONTINUED TO PAGE 10