Forll\ WZ

.
WIT,HHOLDINO STA.TEMENT-19S1

(Roy.July )

~D~~::>'~R.,;.~~Pt!;~::t Wage.
EMPLOYEE TO WHOM PAID

(Prlnt!nC1me, lull C1ddre , C1nd SoclC1i Security

c -(!L-RR I<.

13M Ji... -

EMPLOYEE'S
COPY
(DUPLICATE)

Taxe. Withheld
C1ccounl number)

SS IVb, 1f q 10 -)S' ~5''J /

(Jq f{) prO AI

/'321 S,

S '{,1- 0

r. f. C. A.

Paid and Income and

{.,L

I S if

. -

{VI (i),

:~~~!~~~~~i~=~~~~~1
::~~~:!~~~tOY~~
__:~~
__:~~~:~~:~~~)sp~~:~e~_~~_~~:~:~~
I:~~~d~:i~~c~:e
:~_=~~
FEDERAL INSURANCE CONTRIBUTIONS ACT

EMpLOY R BY WHOM PAID

(NC1me, C1ddre

INFORMATION FOR INCOME TAX RETURN

C1nd IdentilicCllion

S 7-/4: Ny~5fY{rlR.D t?lf3/~b.r)f3-(j{dJ.~1'7'r

S1',,1/+ f!.. J.) -If {)...
~1<
f J'i '/
3'J..O/ ei4 R. o l: I 1\11=

,re

gj, J..ou-/S4)f'i16

"PO

16-G2627-2

KEEP THIS COPY

rOR YOUR OWN RECORD
"'If your wages were subject to F.LC.A. taxes, but are not
shown, your F.LC.A. wages are the same as wages shown
under "INFORMATION FOR INCOME TAX RETURN,"
but not more than $3,600.

EMPLOYEE'S

CO!'Y
(DUPLICATE)

iojal f.I.C.iI. wages Ibeforepay.

roll deductions) paid in 1951

f.I.C.A. employee tax ~

withheld, if any
ro

INFORMATlO fOR INCOMf TAX RfTURN

Tota! wages (b~for.e payroll federal income tax withheld.
deductions) pald In 1951
if any

.~
~

s.. ':

EMPLOY!!. TO WHOM PAID

.e

S .....

3.~

KEEP THIS COpy

496-18. $91
EMPLOY~

WHOM PAID

BY

(Name, address, and identificai:;oil

number)

V, JNe.

SPRINGMElER SHIPPING COMP.

Jl23 HADIEf STIEr

FOR YOUR OWN RECORD

SAJNT OW 1,MO.

43..Q53l9SO
ApFt. B.LR .. 1 '.14-50

Missouri Information Report On Incomes For Calendar Year 1951

rorru No.
Z81

PAYMENTS

MADE MUST BE REPORTED

1 ~

'I,s;

l'i !

1$ I

I'
............................ ~ I~

UliUllilill

,1

lIliliUlfiilaillliliillllliliIlWIIIUi
Ii

EMPLOyg

'

'E

AS SET FORTH

j.

IN SECTION

INFORMATION fOR INCOMf TAX mUIIK

Total 'gages (before payroll

deducliens) paid in 1951

>.

r .

TO WHOM PAID (Print name. full .ddr and Social Security account number)

l.yJl

143.110

DUPLlCAT~
(J)
(J)

1
1
1

o
c

MISSOURI INFORMATION RECEIPT

FOR CALENDAR YEAR 1951

;;0
I

(J)

-I

NOTICE TO PAYEE

EMPLOYE! BY WHOM PAID

(Name.

addr65s, and IdentifJeatfon

number)

This report is a duplicate of State Income Tax Information Report,

Form 28-1 and shows amount of compensation, dividends and other
income paid you during the year 19~1. We are required to furnish
this information to you on or before March 1, 1952 to enable you to
file a correct income tax return with the Director of Revenue, Income
Tax, Box 329, Jefferson City, Missouri, by March 31, 1952.

I\)

o
I
~
I

I\)

IMPORTANT
Employee

Keep this Receipt

o
o

r
I
(Pr int employe2's ecctc l !l:SC1HHy account
name, and fnn c dd re ss b elov.)

BInil

number,

..,t,~111e'y Smard D/B/,

;-,tunly -mard ?uckpoint

1~21 Eo. Compton 'va

. t , I,Qui e
.~ your wag:as
:sroUl"FJ.C.A.

Viera subject

wages

c.

to F.Le.A.

3201 Carolin~ tit.

~t. Louis,4, .
0.

to xes, but are

are the s-ame (!5 wages

T.lL"'{\';ITI1:{CI ..DING I:!~0:11fAT!On."

shown

under

blAt not more

aoov9,

~mL~E:

"U. S. INCOME

Do }'lOT

net shown

than $3,600.

WITHHOLDING

U.S.T!:.~:!rtment

Detach
SC-:2U

this copy and

it to the Dieeotor

keep it as

of Intornal

of your

part

Ii-GV'(JZ1ue

w!th your

TOh::t1l.

STATEMENT-1953

INSURANCE

CONTRIBUTIONS

ACT

U. S. INCOME

(FEDERAL OLD-AGE AND SURVIVORS INSURANCE)

tax records .
income

-tcrx

)6-673]2-1

EMPJo:.t;EE1S

Federal Taxes Withheld From Wages

Internal RevenueService

FEDERAL

42-0028';;7'.:>

R-I-50

Cla.rk

(DUPLICATE)

TAX WITHHOLDING

INFORMATION

(TO BE REPORTED ON EMPLOYEE'S INCOME TAX RETURN)

TotaIF.I.C.A.wages (beforepay- F.I.C.A. employee tax with- Total wages (before payroll de- Federal income tax withroll deductions) paid in 1953*
held, if any
ductions) paid in 1953
held, if any
$
$
$
$

S45.~O
(Print employee's

EMPLOYEE

name,

12.74number,

social security account

and

full address

o.s'.
En-.il C Clark

1"Z21 S.C mpton

t. Leu t a, 0 .

~45.00
(print employer's

EMPLOYER'

uCRQ

identification number,
name, and address below)

below)

9 ..
,L8-8!) 1

4 - 63:;871
J hn F Kn llh

ve,

32t8 A P 1'1< liV

St..

If your wages were subject to F.Le.A. taxes, but are not shown above,
your F.I.C.A. wages are the same as wages shown under "U. S. INCOME
TAX WITHHOLDING INFORMATION," but nol more than $3,600.

Lo is t

'

ff
"

0,.

EMPLOYEE:
Detach this copy and keep it QS part of your tax records.
Do NOT send it to the District Director of Internal Revenue with your income .
tax return.
16-61312-2

u.s.Tr.:s~:;~rtment
Internal RevenueService

WITHHOLDING

STATEMENT-1953

EMPcro~

Federal Taxes Withheld From Wages

(DUPLICA~

$
EMPLOYEE

(print employee's social security account number,

name, and full address below)

EMPLOYER

(Print employer's identification numt.;r,

name, and address below)

S.S~ 496-j. -8b9l

Emil C Clark
1321 ~. CQmptn
st. L uis,Mo.

Ave.

*If your wages were subject to F.I.C.A. taxes, hut are not shown above,
your F.l.e.A. wages are the same as wages shown under "U. S. INCOME
TAX WITHHOLDING INFORMATION," but not more than $3,600.

L ster B rnrueter
424 Belv der Lane
Glendale

EMPLOYEE:
Detach this copy and keep it as part of your tax records.
Do NOT send it to the District Director of Interoal Revenue with your income
tax return.
16-67312-2

"-I...

I 0.11 t:3

't.

1r.'.1,

Type or print EM~LO~

SOCIAL

WITHHOLDING TAX STATEMENT

t.er

1955,Feneral Taxes W thheld From Wages

. .

43-0688 62 ~ .

S Identl~catlOn number, name, and address above,'

SECU !TV INFORMATION

CopyC--For

Emp1oyee's RecordS

IN OMf:' TAX INFORMATION

5;).-;;./9,

F.rt.h.
employee tax
withheld, if any

f::7

.:

Federm'In~~e
if any.'

..

Tax ''withheld
.
,.'

1 r

CO' toll. n
,

'\l

0 .

-18-a.. 1

Type or print EMPLOYg'S

FORM

social security account no., name, and address above.

W-2....:.u.s.Trea~pry

.NOTICE:. If your wages were subject to Social S'ecurity taxes

but are not shown, your Social Secu ity wages are the same
a's wages shown under "INCOME TAX INFORMATION"
but not more than $4,200.
'
Keep this copy as part of your tax records .

,
'Before

payroll deductions.

c9-16-70~28-1

Department, Internal Revenue Service

\.
'\

WITHHOLDING TAX STATEMENT

Federal Taxes Withheld From Wages

,.

-,

1957

Copy C-For Employee's RecordS

SOCIAL

ee

SECURITY

.15

$ .

INFORMATION

Total F.I.C.A. Wages*

paid in 1957

INCOME

F.I.C.A. employee tax

withheld, if any

6.7iJ

Total Wages*

TAX INFORMATION

117.1

paid in 1957

Federal Income Tax withheld,

if any

NOTICE: If your wages were subject to Social Security taxes,

but are not shown, your Social Security wages are the same
as wages shown under "INCOME TAX INFORMATION,"
but not more than $4,200.
Keep this copy as part of your tax records.

Type or print EMPLOYEE'S social security account no., name, and address above.

FORM W-2-u.s.

IL.

Treasury Department,lnternal

~~~~

Revenue Service

A_

~~

__

'Before

payroll deductions.

09-1&-72856-1

~~------~~----"'"'--A~~.~~ ~
f

WITHHOLDING TAX STATEMENT

1957

Federal Taxes Withheld From Wages

_---=S-=O:..:C:.:.:IA..::L~SE::.:C::.:U:.:.R~IT:....:Y,.::.I

N.:.:F:..:O:.:.R:....:M.:.:A.:...T.:...IO.=.:...N~-+

...

$
Total

F.I.C.A. Wages*
Paid

Type or print

EMPLOYE!'S

Type or print

~I:....:N~C~O.:...M:....:E::....:.:T
A.....:X..:.-.:.:IN...:,F.....:O=-R...:.M...:.A...:.T_I..::.O_N~---, __
$

F.I.C.A. employee tax

withheld,
if any.

in 1957.

identification

EMPlOYEE.'S

number,

social

security

name,

Total Wages*
and

account

Copy C - For Employee's Records

address

no.,

name,

Paid in 1957

federal Income Tax

withheld.
if any.

below.

and

address

below.

NOTICE,
not shown,
under

Internal Revenue Service

*Before

If your

wages

were

your

Social

Security

"INCOME

Keep
FORM W-2 - U. S. Treasury Department,

SSINGlE
M.MARRIED

to Social

wages

TAX INFORMATION",

th is copy
Payroll

subject

as part

deductions

of your

are

Security

the same

but not more

tax records.

to xes, but are

as wages
than

shown

$4,200.

WITHHOLDING

CITY OF ST. LOUIS

CITY TREASURER'S OFFICE

Room 220, City Hall

12th & Market Streets

ST. LOUIS 3, MISSOURI
STATE 300 00 116 FED. 43 6003231 W 5.5. 569 04 30 284

EMPLOYER'S

Print

identification

..

number,

nome,

and

TAX

STATEMENT1962 '

F,d,ral Tax.s Withh,1d from Wag.s

Copy C - Fo, Employu'.

address

above

~:1~~1

SOCIALSECURITY
INfORMATION

rl":'. ~~n::.:.It+--_-;:TO~T.;;-t
T:f.I.7:C~~.
W:;;;.;;GE:;-I
-r--;f~.I.C;-;
2. Mo~d

(a,foro PoyrollDtd",ions)
J PAIDIN 1962

.-:'::mp:;::~Y::II-+--:-TO::'OI7.w:-og-"-;::(8'-;fo-ro7po-ytol-:;-""-f-EO-ER-At:"'fN':"CO-ME-TA-X-lox w,'hh,ld.
if ony

O,duet,oo,0,1", Pay"Ex<lu"on.)
Poidin 1962

I
::

""'"

:.

EMPLOYEE
NO.

EMPLOYEE'S

Print

social

WITHEtO
H . If ANY

St. Louis
Earnings
Tax
-c

R.co,J.

INCOMETAXINFORMATION

.. Missouri tax
withheld, if any

\oClAlIECURITY
NO.

security

account

no.,

name,

and

full

address

above.

FORMW-2
U. S.

Treasury Department,

Internal Revenue Service

Excludable

Keep this c,;}p~~:I;a~~

~l:oouu/t;:~:~o~d;~
subject

eater

Under

Section

105

to Social Security texes, but

(d)
lire

not shown, your Secle! Security

wlIgel

rnruet r

arc the some

1383.00

INFORMATION

INCOME

$
F.I.C.A. employee tax
withheld, if any

~2.27

$
Total F.r.C.A. wages
paid in 1962

1962

Copy C-For employee's records

identification number, name, and address above.

SOCIAL SECURITY

but not more the" $-i,800.

Federal taxes withheld from wages

43-0688,3()2
-

shown under "lneeme T.x Inform.tlcn,"

WITHHOLDING TAX STATEMENT

3642 Arkansas Ave.

st. oU1sJ18, o.
Type or print EMPLOYER'S

tiS wlIges

TAX INFORMATION

1)83.00

13 .3

2$.90

$
Total wages* paid in 1962

$
Federal Income tax withheld,
if any

1 C.C1ark
)20 A. ar~ ve.

City Tax

NOTICE: If your wages were subject to social security

taxes, but are not shown, your social security wages are
the same as wages shown under "Income Tax Informstion," but not more than $4,800.
Keep this copy as part of your tax records.

St.
touis,!,.. o.
'+96.18.8591

Type or print EMPLOYE.1!;S social security account' no., name, and address above.

IFORM W-2-U.

s. Treasury

'Before payroll deductions or "sick pay" exclusion.

Department. Internal Revenue Service

Copy C-

;L8ster Bernruetel'

WITHHOLDING

: 3642 Arkansas Ava.

i St.Louis,la,Mo.

or print

name,

,
,,

115-0844.1

Missouri Income Tax Withheld

Typ.~

EMPLOYER'S
SOCIAL

identification

SECURITY

1,383.00
TOTAL F.I.C.A. WAGES
PAID IN 1962

and

address

42.:t.7

F.I.C.A. EMPLOYEE TAX

. WITHHELD. IF ANY

INCOME

1,38).00

TOTAL WAGES IBEFOREPAYROlL

DEDUCTIONS) PAID INI962

496-18-8591
FORM MoWH-2

TAX

ADDRESS

Missouri Department of Revenue, Jefferson City

1962

Employee's Records

INFORMATION

2S.yo

FEDERA INCOME TAX

WITHHELD, IF ANY

CitY' Tax 13 8,3

Emil C. Clark
)208 A. Park Ave.
St.Lou1s.4.. to.
TYPEOR PRINTEMPLOYEESSOCIAL SECURITYACCOUNT NO.,NAME,AND

Copy C-For

above.

INFORMATION

)$

number,

TAX STATEMENT

2.70

MI SOURI TAX
WITHHELD, IF ANY

WAGE ANIrAX STATEMENT

INCOME
Federal

Income
Withheld

TAX INFORMATIOI

Wages 1 Paid
Withholding

Tax

Other

Subject
To
in 1965

Compensation
paid in 1965

EMPLOY!E.'S social

or Print

security

no.,

name

and

a ess

'-.

I "4

It '"

EMPLOYEE

below.

J.'

If NONE

or

and

.;:

and

salaries

If your

on your

wages

FORMW-2-U. S. Treasury

I I
Deportment,

01 your

~to~~~
than

s4,800

tax records.

I Revenue Service APP.

4-26-65

fiNDTAXSTATEMENT
Copy C - For employee's

'="";

~-, Type or print EMPLOYE'S

;J

more

.'
..E~

seC~h~\~::s~s

n erne

, ~- ~~="':"':":'=~--~----IWAGE

records

19 6 6~

KEEP THIS COpy AS PART OF YOUR TAX RECORDS

'

NAME of STATE (or City)

identi/icotion

number.

"r ".c:~,:~;,.:~::

return

SOCIal

;,

lill ;,
f I!! J

"'"

tax

to

Keep this copy as part

.a
,g

~
~a

Income

subject

were

not shown,
your
socloTI s~Cfrl~a~~~~,Sb~r~ot
shown
under
"Income
ax nor
,

address

300-0(H6

Print

EMPLOYER'S
identificotion
number, nome

f 3,6rn]3$~'

011:"NONE"

payroll
deductions
or "sick pay" exclusions.
.
"
ans ction"
is for use In reportThe block marked
Other
c~.mp which was not subiect to with
ing salary
or ot.her compen:taofl~~e
reported
on Form
1099. ~
holding
and which wa~ hef.r
.
the amount
to be reported
as
this
item
to wages
10
Igurlng

SICK PA Y
'0'

EN1EII:

Before

wages

~
~
s
~
~
e
~
,~

'11

I~ I

Type

denh

-,

EXCLUDABLE

NO.

,"""

Tax Withheld

,,

,
1i .a

Type

State

F.I.C.A. Employee
Tax Withheld

2'

and address

City or Other
To,

above

-: endnddrevsbe..

1 = Single

2=

MaHied

No_of

Dependents

Employee
Number'

\:.

State Gross Income.

If Different Than
Federal

st=

~I~~

..'" "'"
U

:;)

=~~_-~~.i'~""~:['.~,:;_io!,~

__

~~~-:_;.;l:Eo------------------------~IN~(on.M~E~T~A7X~IN~f~O~RM~A~T~IO~N------------------------~~S~07.(I~Al~SE~(U~R~IT~Y~I~Nf~O~RM~A~T~IO~N-'--~------'_

~aa~

. ::

~.

,H hJi

Federal Income Tax Withheld

Wages lpoid subject to

withholding in 1966

Other compensation
paid in 1966

~:O...t~li~:~e~de

F.I.C.A. employee Total F.I.C.A. wages

tax withheld 3
paid in 1966 4

"

----------f------+~--t_---:-_+~-_+--_+_-~
"Trii;MiA;::;::;;~=;n:;;;:::;:::::;_;:;::_:::::r;;::=:::::<:::::;::_L--tl--a--1--2--60--
~L--~~~L4--0--,z~O--"'2~.....--~~L-~
FORM W-2-U.S.

Treosury Deportment, Internol Revenue Service

__L

",

'tndudes tips reported by employee. This amount is before payroll deductions or "sick pay" exclusion.
'Add this item to wagls in figuring the amount to be reported as wag's and salaries on your income tax ntum.

Type or print EMPLOYER'S

Federal income
tax withheld

identification

number,

FliDERAL INCOME TAX INFORMA nON

Wages1 paid subject
to withholding in 1967

I
I

Type or print EMPLOY~'S

security

number

social
~

name and address

Other cornpensction!
paid in 1967

obove.

"lhe social security (F.I.C.A.) rate of 4.4% includes .5% for Hospital Insurance Benefits and 3.9% for old-age, survivors, and
disability insurance.
-lndudes tips reported by employee
If your wages were subject to social security taxes but ore not shawn these wages
are the some as wages shown under "Federal Income Tox Information, but not more thon $6,600.

SOCIAL SECURI
F.I.C.A. employee
tax withheld"

INFORMATIO
Totol F.I.C.A. wages'"
paid in 1967

CITY TAX WITHHELD

STATUS
l-S~~rif
2-Married

Gross Wages from Stcte

different from Federal

STATE TAX WITHI;iELD

NAME OF STATE

STATE FORM NO.

NAME OF CITY

CITY FORM NO.

I
I
I

**
"UNCOLLECTED

EXCLUDABLE SICK PAY

Type or print EMPLOYEE'S

nome and address

(including

ZIP code)
,-

above.

FORM W-2-U.S.

~___:_

*EXCLUDABLEUNDER 105(d)

Treasury

Department,

Internal

EMPLOYEE TAX ON TIPS

Revenue

Service

APP. I.R.S. 1-12-67

~~m

g .~

'Ii

S Ind"Y"dual
I I
I ncome Tax Return

Ll.. U

~
.

1. Check and correct any information in boxes 1,2, and 3.

i~~!
EMI L
~~
~
"
3l08A
_

C {, MI I..DRED
PARK AVE
5T L.OUIS MO

~~4331~
:;: -

""0

~ ill

If item 7 is $10,000 or more, or

if total income from interest, dividends, and nonwithheld wages is
over $200, use Form 1040.
2. Your social security number

CL.ARK

~~na~~~~d
filing joint reo
3. Spouse's social securilynumber
!urn(evenifonlyonehad
Income};
497"!'20.9155
Dc.Marriedfili~gsepara!e.
Iy-If spouse IS also filing
a return, enter her (his) social security number in item 3 and give first

63104

~:

~~

4. Check one:

496.18!!"8591

name here ~

Enter below name and address used on your return for 1966. 5. Enter total wages, salaries, tips, etc. Enclose
yours.... i~qt:7
i, /
. ...1
(If same as above, write "Same.") If none filed, give reason, If
F
W 2 C
B
If
hid
."...
/ 1..1
(./
changing from separate to joint or joint to separate returns,
orms -,
oPY not s own on enc ose
- ---- ------ :-----enter 1966 names and addresses.
Forms W-2 attach explanation,
Spouse's ~
I1--..:.....:.:..:..:..:.:.....:..:..:...=..=:.:.=:.:...:.....:...:::..:..:..:..
..:..-_------'-----1----------------:------

:~~~~~~~~~~~~~~~~~~~~~~~l~~t!~~~~~~~~~~~~~
:-----==~-+----6a. Interest

1:-:----;-------::-=-::-::-:----------------16b.
If your income was $5,000 or more, you must compute your tax.
If inccme was less than $5,000, you may have the Internal Revenue
=~~~~oH!~te9tulf
~~ub~o~~i:ngy~~~m:w~, ~~: ~~~ 1~1~~:
(item 10) in full with your return.
Apply
D &U.S.
Savings Bonds,
D Refund only.
refund to:
excess refunded; or
LIST YOUR EXEMPTIONSAND SIGN ON OTHER SIDE.

spo::~~

Dividends: Yours-before exclusion

$
(See instr_) Spouse's-before exclusion $------------......
::
9.

~::a~r~:o~:
~:~~e i::~:x 5~0:~u::~0~b~chedule
Total Federal income tax withheld (from Forms W 2)
10. If item 8 is larger than item 9, enter
Balance due
11. If item 9 is larger than item 8, enter
Refund

J:HECK NO.

THIS STUB TO BE DETACHED AND

706329

RETAINED BY EMPLOYEE

STATEMENT
FEDERAL
WHo TAX

GROSS

DEPT.

I
I

610
R~

KEEP
I
I
I
I
I

21~! ,,5
PENSION
I
I

41 29
I

dry

I
I
I
I
I

TAX
I
I

I
I
I
I

BONDS

OF EARNINGS

2! 1'+
F~

UN. DUES
I
I
I
I

AND

DEDUCTIONS

F.I.C.A.

STATE TAX

I
I

I
I
I
I

9: ~J
HOSP. &
BLUE CROSS
I
I

81I 713

DATE
MO.

YR.

DAY

12 22 67
NET AMOUNT

CHARITY
I
I
I
I
I

I
I

SO

-------=-----1------

After ~
After ~ -------.:.:.:.:.:----1-----,-

189: 11

CITY OF ST. LOUIS

ST. LOUIS, MO.

::_~=_=~
__
.:::::,i,: ~~

I
!

Regular

12. EXEMPTIONS FOR YOURSELF-AND

SPOUSE (only if all her (his)
income is included in this return, or she (he) had no Income)
Check boxes which apply
)

fI I r1'.- L..{J/l#-rr4

13. First names of your dependent

children who lived with you

14. DEPENDENTS
OTHERTHAN
THOSE
CLAIMED
IN ITEM 13.

(a) NAME
.. Enter figure 1 in the last eelumn to right for each name listed
(if more space is needed, attach
schedule)

15. TOTAL EXEMPTIONS

Your present

employer

er

Yourself.
S
pouse.

.rfr

:J. ~~e;P#- (1 !1ES

(b) Relationship

(e) Months- lived

in your home. If
born or died duro
ing year also write
"8" or "D"

65 or over

Blind

0
0

0
0

Enter number
of boxes
checked

-/-/\It -C!.-1t7.1z'eg/,v14
(d) Did
dependent
have income
of $600 or

more?

~~~~er

(e) Amount YOUfurnished for dependent's support.

If
100% write "ALL"

Amount furnished
by OTHERSincluding
dependent. See lnstruction 14

~irY

If you had an expense allowance

Under penalties

5r-

"J; c. 1- t..V' {// s E )(c r s e:

c-ao 1$ I'1P.

or charged

of perjury,

your..siiiiiiliiire -

expenses

to your employer,

",.bjpouse's

I City

2b

-- --
g

It~VSfv/P

employer

and State where employed

see instructions

I declare that to the best of my knowledge

present

(f)

FROM ITEMS 12, 13, AND 14 ABOVE ...........................................

City and State where employed

Sign ~
here ~

for "Reimbursed

Expenses"

and belief this is a true, correct,

-.-

- ..- ..- ..-

and check here

and complete

- ..- ..----~--.-----------

0 If appropriate.

return.

..Datii---