CONFIDENTIAL
VOLUNTARY ENTRIES
UNION TRUST CO. OF D.C.
ARE YOU A MEMBER OF THE NORTHWEST FEDERAL CREDIT UNION? [ ] YES [X] NO
IF YES, DO YOU HAVE A JOINT ACCOUNT? [ ] YES [X] NO
HAVE YOU COMPLETED A LAST WILL AND TESTAMENT? [X] YES [ ] NO. (If "Yes" where is the document located?)
UNION TRUST CO. OF D.C.
HAVE YOU DESIGNATED AN INDIVIDUAL (GUARDIAN) OF YOUR CHILDREN IN CASE OF COMMON DISASTER TO BOTH PARENTS?
[ ] YES [X] NO. (If "Yes" give name(s) and address(es))
HAVE YOU EXECUTED A POWER OF ATTORNEY? [ ] YES [X] NO. (If "Yes" who possesses the power of attorney?)
ADDITIONAL DATA AND/OR CONTINUATION OF PRECEDING ITEMS

RESIDENCE DATA - TO BE COMPLETED ONLY BY EMPLOYEES ENTERING ON DUTY
CHANGE IN PERMANENT PLACE OF RESIDENCE (SF 171-22)
DATE: 4 May 71
SIGNATURE: [Signature]
CONFIDENTIAL