Transcript of 180-10060-10468.pdf
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Assassination Records Review Board
Final Determination Notification
AGENCY HSCA
RECORD NUMBER 180-10060-10468
RECORD SERIES STAFF PAYROLL RECORDS
AGENCY FILE NUMBER
December 8, 1995
Status of Document: Postponed in Part
Number of releases of previously postponed information: 14
Reason for Board Action: The Review Board's decision was premised on several factors
including: (a) the significant historical interest in the document in question; (b) the
absence of evidence that the release of the information would cause harm to the United
States or to any individual.
Number of Postponements: 10
Postponements: All the postponements in this document represent Social Security numbers
Reason for Board Action: The text is redacted because the public disclosure of the redaction could
reasonably be expected to constitute an unwarranted invasion of personal privacy, and that invasion of
privacy would be s0 substantial that it outweighs the interest:
Substitute Language: SSN
Date of Next Review: 2017
Board Review Completed: 10/24/95
xelbased under the Jonn
Kennedy Assassination
Records Collection Act of
992 (44USC 2107 Note)
'ase#Nw 88326Date:
PQ25
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Date: 08 /20/93
Page: 1
JFK ASSASSINATION SYSTEM
IDENTIFICATION FORM
AGENCY INFORMATION
AGENCY HSCA
RECORD NUMBER 180-10060-10468
RECORDS SERIES
STAFF PAYROLL RECORDS
AGENCY FILE NUMBER
DOCUMENT INFORMATION
ORIGINATOR HSCA
FROM
TO
TITLE
DATE 12/06/76
PAGES 16
SUBJECTS
HSCA ADMINISTRATION
LEHNER ROBERT
DOCUMENT TYPE PRINTED FORM
CLASSIFICATION U
RESTRICTIONS 3
CURRENT STATUS P
DATE OF LAST REVIEW 06/04/93
OPENING CRITERIA
COMMENTS
Box 2
[R] ITEM IS RESTRICTED
NW 88326
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C
LEHNER , Robert OFFIcE OF THE CLERK
Nima 0i"Employcc U.S, KOUSE CF REPRESENTATIVES
DALANCE QiouGkt
Fonyiro Fnos PERSONAL LEAVE RECORD Pneceding YEAK
Addrcas
Ajincji Sick L47
Lasc [eaya
Ajdiess YEAM
123 73
ANNUAL LEAVE
daTE Of APpointMENT
Phone Nembcr CATeGORY
12 -(-7 (
1.0
Posilion Tifio 1,5
Paior fedEgAL SeRvicc
;ionit; 2,0 AcCRWED AVAIaoLe USed RALiTSE
po;iinu Number Lcvci Sicp this Montk This Moxth Tims roiitx 0f Mobik
8
DAY OF MONTH Annual. Sick Acc"al Sick Annual Sick Xcnual Sick
E
1
Uca!h
1 0 TTTa 15 Jc 17| 18 / 19 | 20 2122 23| %4 | 25 20 27 28 2 30 31 Leavc Leavc Lejic Lcayc Leave Lcav: Leaw? Leave
Jan.
13
Fcb:
^pr,
Jugc
July
Aug,
Scpt;
Oct_
Nov.
Dec,
Jludy <.
= 0.5 dy annual Icavo
Zmmai xhel
CORRECT;
sr
= 1.0 Jnnual Icjvo
amuuyy &uy
= 0,5 sick leave
Lalna
4
Ln_bla :
5
S = 10 day sick Icavo Employco'; Sicnaturc Dutc Chia('$ Sienatero Data
(If cmployce rcluscs fo Slcn, stalc rcasan bclow:'
0.5 admlnistrativc Ieavo
1.0 day adminiskralivc Icavc Approvcd:_
Clcrk cl Khc Mouso Dato
= 0.5 dby unjulhorized abscnco
This rccard will be (crwardcd to thc Clcrk of thc Housc at thc cnd of cach calendar ycar; orin casc cf termination, along
= 1.0 unaulhoxizcd Jbscnca with tho rcqucst {or tcrmination. Upon ?pproval, thc Iccord will bc Iilcd in thc omployec"$ Ollicial pcrsonncl {oldc;,
= 0.5 dpy Icava without Pay
= 1,0 doy Icjyc wilhou: PJY
EXHI I
NW 88326
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Mar;
May:
ESERTIFIED
day
doy
djy
day
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Louis Stokes; Ohio; Chairma
RICKARDSON PREYER, nc; IAMUEL L Devine, Ohio
WalteR E: FAUNTROY, Dc: STEWART 0: MC KINNEY , CONN:
YVONNE BRATHWAITE Burke; CaALIF, CHARLES ThONe; NebR:
CkribtophEr J: DODD; CONN:. MAROLD 8. SAWYER; Mich:
NaROLD E: Ford; TENNL : Select Committee 0t @sgassinations
FlOYd J: FITHIAN; IND:
ROBERT W: EDGAR; PA:
@.S. {ouse of. Rkeptesentatibes
(202) 223-4624
3338 House OppiCE BULDING, ANNEX 2
WASKINGTON; D.c: 205f$
September 19
9
1978
U : S Department of: Justice
Personnel Room 6248
10th' & Pennsy]vania Avenue, N_ W.
Washington, D . C_ 20530 Attention: Susan Reneer
Personne] Office:
In resonse to your telephone inquiry
8
we are verifying the
fo]Iowing information on Robert J. Lehner
Appointed: December 6, 1976
Teminated: February 28, 1978
Salary: S45,500 . 00
Sincerely
"nitl
Imas
THOMAS KOWARTK
Budget' Officer
TH:ht
NW 88326
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PAYROLL AUThORizaTiON FQS
(Please Use Typewriter U.S. HOUSE 0f REPRESENTATIVES (Any erasures; corrections; or changes
or Ballpoint Pen) Washington, D.C. 20515 0n this form must be initialed by the
authorizing Official.)
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee Name (First-Middle-Last)
Effective Date
Rcbert J Lehner February 28, 1978
Employee_Social Security Number Type of Action
071-28-5111 Appointment
Salary Adjustment
Employing Ofice or _Committee /Subcommittee Title Change
'Termination (Af close of business on effective date)
Leave without pay (Beginning with effective date above and ending
Select Cozi ttee on Assassinations
close of business_
Specify Date
(If type of action is an Appointment, Salary Adjustment, or Title Change; complete appropriate information below:)
Position Title Gross Annual Salary
* If emoloyee is a civil service annuitant (includes U.S. House of Representatives), the gross annual salary shown should include the annuity received by the employee
plus the salary received the employing office.
(If Committee Employee, complete appropriate item below:)
Standing Committee: Staff Clerical or Professional:
23 (Investigative staff of Standing Committee) or Select Committee: Authority-_H:
879_of_9526
3. Joint Committee.
(If Employee of an Officer of the House, complete item below:)
Position Number_ If applicable, Level Step_
certify that this authorization is not in violation of 5' U.S.C 3110b), prohibiting the employment' ` of
relatives:
February 16
9
78
Date_ 19_
(Signature of Author Official)
Louis_Stokes_
(If appropriate, signature of Subcommittee Chairman Or
Ranking Minority Member)
(Type or print name of Authorizing Officiol)
Chatbgan_
(Type or print name and title of above official) (Title - If Member , District and State)
All appointments and salary adjustments for employees under the House Classification Act and for Committee em-
ployees, except those of the Committee on Appropriations, the Committee on the Budget, and the Joint Committees, must
be approved by the Committee on House Administration
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only:
Office Code.
Benefits
Monthly Annuity $__ .00
as of Payroll _
(Revised: August 9771 for Initiating Office or Committee
NW 88326
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Yspecial
Res __ Congress:
rizing
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M E M @ R 4 N @ U M
TO: Thomas Howarth
1
Budget Officer
FROM: I_ Charles Mathews _
1
Special Counsel
Vei
DATE : February 14 , 1978
RE : Mr Robert Lehner
Effective Tuesday , February 28 _ 1978 _ Robert Lehner
will be terminated from the Committee payroll_
If you have any questions concerning this matter ,
please contact me at your convenience _
ICM:j
NW 88326
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PAYROLL AUTHORIZATION " FORM
(Please Use Typewriter: U.S,:HOUSE *OF: REPRESENTATIVES (Any; erasures; corrections : or:changes
or Ballpoint Pen): Washington;, D.C.-20515 on. this form: must: be initialed byathe
authorizing Official.)
To the: Clerk: of the House gf Representatives:
hereby authorize the following payrollaction:
Employee Name: (First-Middle-Last) Effective 'Date:
Robert J=
0
Lebner December 1
9
1977
Employee Social-Security Number Type 'of:Action'
071-28-511} Appointment:
Employing Office 0r Committee Salary Adjustment
Assassina tjons Termination (At close of business on effective date)
(If type of action-is:an Appointmenf or Salary Adjustment; complete-the following information:);
Position: Title Gross Annual Salary_
Deputy Chief Couase] 305
4
500
(If Committee Employee;complete appropriateitem below:):
Standing Committee: Staff: Clericaltor Professional:
2. Speciol or Select Committee: Authority-H: Res:__AGS___~of_@EttCongress:
3; Joint Committee:
(If Employee of an Officer of the: House; complete item below:)
Position Number If ~applicable; Level_ Step_
'certify =that: this: <authorization' is not in' violation: of: 5 U.S.C, 3110b), prohibiting the 'employment: of
relatives.
[tt-
Date_
Dacember 1927
(Signature of Authorizing Official)
Louis_Stokes
(Type Or 'print name of Authorizing Officiol)
Chalman
(Title - If Member, District and State)
All - appointments and salary adjustments for employees under the House Classification Act: and for: Committee em"
ployees; except those of the Committee on-Appropriations;the 'Committee' on the Budget,and:the 'Joint-Committees; must:
be approved by the Committee on House Administration:`
APPROVED:_
Chairman, Committee' on House Administration
Office of Finance use only:
Office Code_
Monthly Annuity $_
for Initioting ' Office: or: Committee
NW 88326
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PAYROLL AUTHORIZATION: FORM
(Please Use Typewriter' U.S: HOUSE ' OF: REPRESENTATIVES (Any erasures, corrections; or:changes 4
or Ballpoint Pen) Washington; D.C. 20515
on this form must be initialed: by the
authorizing Official.)
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee Name_ First-Middle-Last) Effective Date
Robert J , Lehner 8/1/77
Employee Social Security Number Type of Action
071-2&-51H1
Appointment
Employing Office or Committee Salary Adjustment
Assassinations Termination (At close of business on effective date)
(If type: of action is an Appointment or Salary Adjustment, complete the following information:)
Position Title Gross Annual Salary
Deputy Ch?ef Counsel 42
9
500
(If Committee Employee, appropriate item below:)
1 Standing Committee: Staff-L Clerical or Professional:
2_ Special or Select Committee: Authority
5
H: Res:_465___of_9Eth Congress:
3. Joint Committee.
(If Employee of an Officer of the House, item below:)
Position Number_ applicable, Level_ Step__ _
certify that this : authorization. is not in violation' of 5 . U.S:C: `3110b); "prohibiting the: employment *of
relatives.
Date_ August_2_ 19_71
Uh0yo ++
(Signature of Authorizing Official)
LQpiS__STOKES
(Type or print 'name of Authorizing Official)
CHAIRNAA_
(Title ~ If Member, District and State)
All appointments and-salary:adjustments for employees: 'under-the House- Classification Act and:for: Committee:
ployees, except-those of the Committee' on Appropriations; the Commifteef on the:BBudget; andtthe-Joint Committees; must
be approved: by the Committee :on House Administration::
APPROVED:_
Chairman, Committee on House" Administration:
Office of Finance Use only:
Office Code_
Monthly Annuity $_ 00
for 'Initiating ffice Or Committee
NW 88326
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complete
complete
~_If
em-
Copy'
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PAYROLL AUTHORIZATION FORM
(Please Use Typewriter U.S. HOUSE 0F REPRESENTATIVES (Any erasures, corrections, or changes
=or-Ballpoint-Pen) Washington, D.C. 20515
0n this form must be initialed by the
authorizing Official.)
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee_Name_(First-Middle-Last) Effective Date
Kobert J Lebnet 7/17/77
Employee Social Security Number Type of Action
071 28 5113
Appointment
Employing_Office_or_Committee_ Salary Adjustment
Assassinatdons
Termination (At close of business on effective date)
(If type of action is an Appointment or Salary Adjustment, complete the following information:)
Position Title Gross Annual Salary
536
S
Q}
(If Committee Employee, complete appropriate item below:):
Standing Committee: Staff-LJ Clerical or [ Professional.
2 Special or Select Committee: Authority-H. Res__ 8r of%5th_Congress
3. Joint Committee.
(If Employee of an Officer of the House, complete item below:)
Position Number_ If applicable; Level Step_
1 ~certify: that this authorization is not in violation of 5 U.S.C. 3110b); prohibiting the employment of
relatives.
Date
Jmly 14 1977
~~ (Signature of Authorizing Official)
Louis Stokes
(Type or name of Authorizing Official)
Ciairwat}
Title ~ If Member, District and State)
AlI appointments and salary adjustments for employees -under the House Classification Act and for Committee "em-
ployees; except those' of the Committee on Appropriations, the Committee' on the Budget; and the Joint Committees, must
be approved by the Committee on House Administration.
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only: lpnn ~
Office Code_
XA
Monthly Annuity $_ 00
for Initiating Office or Committee
NW 88326
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print
n/shn
Copy
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U.S_ Go VERNMEN T PRINTING FFICE: 1977_80-199
PAYROLL AUTHORIZATION FORM
(Please Use Typewriter U.S. HOUSE 0 F REPRESENTATIVES (Any erasures, cofrections, or changes
or Ballpoint Pen) Washington, D.C. 20515
0n this form must be initialed by the
authorizing Ofycial )
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee Name (First-Middle-Last) EWective Date
Robert J . Lehner 7/17/77
Employee Social Security Number Type of Action
071 28 5111 Appointmeht
Employing_Office or Committee Salary 'djustment
Assassinations Termination (At close of business on effective date)
(If type of action is an Appointment or Salary Adjustment, complete the following information:)
Position Title Gross Annual Salary
S36,000
(If Committee Employee, complete appropriate item below:)
1, Standing Committee: Staff-[J Clerical or Professional.
7 -8 77 [ 3 07
2. Special or Select Committee: Authority Res__ 465___of95th_Congress.
402, FIVACE 3770
3. Joint Committee.
(If Employee of an Officer of the House, complefe item below:)
Position Number_ If pplicable, Level_
CCCC~
certify that this authorization As not in violation of 5 U.S.C. 3110b)_prohibiting the employment of
relatives
Date_ L10__ 192Z_
(Signature of Authorizing Official)
Louis_Stokes
(Type or print name of Authorizing Oificiol)
Chairman JAe LeI
(Title ~If Member , District and State)
All appointments and sqlary adjustments for employees under the House Classification Act and for Committee em-
ployees, except those of the dommittee
on Appropriations, the Committee on the Budget, and the Joint Committees, must
be approved by the Committee on House Administration
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only:
Office Code_
Monthly Annuity $_
NW 888326
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p Va
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PAYROLL: AUTHORIZATION FORM
(Please Use Typewriter U.S. ' HOUSE : 0 F REPRESENTATIVES (Any erasures; corrections; or changes
or Ballpoint Pen): Washington, D.C. 20515 on this form must be initialed by the
authorizing official.)
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee Name (First-Middle-Last): Effective Date
Robert J_ Lehner 7/17/77
Employee Social Security Number Type of 'Action
071 28 518] Appointment
Employing Office or Committee Sclary Adjustment
Assassinattons Termination (At close of business on effective date)
(If type of action is an Appointment or Salary Adjustment, the following information:)
Position Title Gross Annual Salary
836,O00
(If Committee Employee; complete appropriate item below:)
1
Standing Committee: Staff-L] Clerical or Professional::
2
Special or Select Committee: Authority-H. Res __ 465 of9Eth_Congress
3. Joint Committee.
(If Employee of an Officer of the House, complete item below:):
Position: Number
C
If applicable, Level_ Step_
certify. that: this authorization is not: "in violation ~of 5 U.S.C. 3110b); prohibiting the employment of
relatives.
Matntanry
Date_
19_ 1977
(Signature of Authorizing Official)
Louis Stokes
(Type or name of Authorizing Official)
Cha {rizan
(Title -If Member, District and State)
AIl-appointments and:salary adjustments for employee
S under: the House Classification Act and for- Committee em
ployees; except those of the Committee on Appropriations;the: Committee on the: Budgetyrand the Joint-Committees; must
be approved by the Committee on House Administration.
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only:
Office Code_ F1
Monthly Annuity $_
_
00
for--Initiating Office or:Committee
NW 88326
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complete
Gel-ot Hay
print
Copy
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PAYROLL AUTHORIZATION . FORM
(Please Use Typewriter U.S.' HOUSE : 0 F : REPRESENTATIVES (Any erasures, corrections; or changes
or Ballpoint Pen) Washington, D.C. 20515 on this form must be initialed by the
authorizing official.)
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee_Name ( First-Middle-Last) Effective Date
Robert J. Lehner 4/1/77
Employee Social Security Number Type of Action
07} 28 5111 Appointment
Employing_Office_or Committee Sclary Adjustment
Assassinations Termination (At close of business on effective date)
(If type of action is an Appointment or Salary Adjustment, complete the following information:)
Position Title Gross Annual Salary
847
9
50d
(If Committee Employee, complete appropriate item below:)
1, Standing Committee: Staff-
~_ Clerical or Professional:
2:
Special or Select Committee: Authority-H. Res_465_
of
95th_Congress.
3_ Joint Committee.
(If Employee of an Officer of the House, complete item below:)
Position Number If applicable, Level
certify that 'this authorization is not 'n violation of 5 U.S.C_ 3110b), prohibiting the employment of
relatives.
Date_ April_ 29 19_72
(Signature of Authorizing Official)
Louis Stokes
(Type or name of Authorizing Officiol)
Chadrran
(Title - If Member , District and State)
All appointments and salary adjustments for employees under he House Classification *Act and for Committee: `em-
ployees, except those of the Committee on Appropriations; the Committee on the 'Budget; and the Joint: Committees; must
be approved by the Committee on House-Administration :
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only:
Office Code.
S~-
Monthly Annuity $_ 00
for: Initiating 'Office or Committee.
NW 88326
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Step_
print
Copy
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PAYROLL -AUTHORIZATION: FORM
(Please Use Typewriter: U.S: HOUSE 0 F REPRESENTATIVES (Any erasures, corrections; or.changes:
Or Ballpoint Pen) Washington, D.C: 20515 0n: this form must be initialed by the
authorizing official )
To the Clerk of the House of Representatives:
hereby authorize the following payroll action:
Employee Name_(First-Middle-Last) Effective Date
Robert J Lehner 2-1-77
Employee Social Security-Number Type of Action
071-28-5171
Appointment
Employing_Office_or Committee [ Salary Adjustment
Select' Comittee Ow Assassinations Termination (At close of business on effective date)
(If type of action is*an Appointment or Salary Adjustment, complete the following information:)
Position Title Gross Annual Salary
$22
9
140
(If Committee Employee, complete appropriate item below:)
I_ Standing Committee: Staff-L Clerical or Professional:
71 95
2_ Special or Select Committee: Authority-H. Res. of_
3 Joint Committee_
(If Employee of an Officer of the House, complete item below:)
Position Number_ If applicable; Level_
certify that this authorization is not: in'_violation , of 5 +U.S.C : 3110b), prohibiting the: employment of
relatives.
2-28-77
Date_ 19_
~t of Authorizing Official) Henry B
GonSza8tvcezF
(ype or print name of Authorizing Official) Chairman
Title ~ If Member, District and State)
All appointments and:salary adjustments for'employees 'under the-House Classification Act-and for Committee em-:
ployees;:except those of the Committee on Appropriations; the Committee"on the: Budget, and the Joint Committees;imust
be approved by the Committee on House Administration:"
APPROVED:_
Chairman, Committeeon House Administration'
Office of Finance use only:
Office Code_
Monthly Annuity $__- 00
for Initiating Office or Committee
NW 88326
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Congress.
Step_
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GPO;;4975,0 +.57-255
PAYROLL: AUTHORIZATION FORM
(Please Use Typewriter U.S, 'HOUSE 0F :REPRESENTATIVES (Any erasures , corrections or changes
or Ballpoint Pen) Washington; D.C: 20515 on this form must be : initialed by the
authorizing official;
To the Clerk of the House of Representatives:
1'
hereby authorize the following payroll action:
Employee Name (First-Middle:Last) Effective Date
Robert J Lehner
4/3t7z
Employee Social Security Number Type of Action'
071* 28 . 5111 Appointment
Employing Office_or Committee Salary Adjustment _
Termination (At close of business on effective date)
Select Cormittee on_Assassinations
(If type of action is an Appointment or Salary Adjustment, complete the following information: )
Position Title Gross Annual Salary
23 40n
(If Committee Employee, complete appropriate item below:)
Standing Committee: Staff_ 'Clerical or Professional:
2 Special or Select Committee: Authority-H; Res.14 of9s_ Congress:_
3: JJoint Committee_
(If Employee of an Officer of the House, complete item below:)
Position Number_ If applicable, Level:
certify": that this authorization' is not in violation 'of: 5 USC 3110b), prohibiting the': employment of
relatives:
Date:_
197
(Signature of Authorizing Official)
Henry @ _Conzalez
{(Type or print name of Authorizing Official) "
Chetrmen
'(Title If Member, District and State):
Allappointments and salary adjustments for employees under: the House Classification Act and for Committee em;
ployees; except those of the; Committee on 'Appropriations; the Committee on the_Budget, the Joint Committees, must
be approved by the Commitee on: House Administration:
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only:
Office Code:
Monthly Annuity $ 00
Ni.88326
Qocid:32239476 14
for Initiating Office or Committee
Step_
and
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PAYROLL AUTHORIZATION FORM
(Please Use Typewriter U.S.HOUSE. OF_REPRESENTATIVES (Any erasures; corrections, or changes
or Ballpoint Pen) Washington;-D.C:: 20515 on ` this form must be initialed by the
authorizing Official.)
To the Clerk of the House of Representatives:
hereby authorize the following payroll' action:
Employee Name (First-Middle-Last) Effective Date
Robert Joseph Lehner 12/6/76
Employee Social Security Number Type of Action
07] 28, 5111
Appointment
Employing Office or Committee Salary-Adjustment
Termination (At close of business on effective date)
Sclect Comaittee on Assassinations
(If type of action is an Appointment or: Salary Adjustment, complete the following information )
Position Title Gross Annual Salary
Deputy Chdef Counse] $36,02Q
(If Committee Employee, complete appropriate item below:)
1 Standing Committee: Staff-[ Clerical or [7 Professional::
2
Special or Select Committee: Authority-H: Res_154Q_ offth_
Congress:'
3. Joint Committee:
(If Employee-of an Officer of the House, complete item below:):
Position Number_ If applicable, Level_
certify. that this: authorization is not in violation:: of 5.-U.S.C: 3110b}; . prohibiting *the: 'employment of::
relatives.
Date_ December 1976_
(Signature of Authorizing Official)
Thonas_!__Downing
9
Chairran
(Type or
print name of Authorizing Official)
Select_Cqmittee_ 0m Assassima tices
(Title ~ If Member, District and State)
All appointments: and-salary adjustments for employees under the House Classification Act:and: for Committee em-
~ployees; except those of therCommittee on Appropriations; the Committee on
the Budget, *and #he loint:Committeeszmust
be approved by the Committee: on House Administration:
APPROVED:_
Chairman, Committee on House Administration
Office of Finance use only:
Office Code_
Monthly Annuity $_
for:Initiating Office or Committee
NW 88326
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M E M 0 R A N D U M
TO : All Staff Employees
FROM: Budget Officer
DATE : January 3 _
1
1977
RE Payroll Certification
Starting with the January 1977 payroll the certification
to the House Finance Office requires _ among other: things , the
relationship, if any of each Staff employee to any current
Member of Congress
those taking office January 3 _ 1977)
The following
are the relationships to be included in
the certification
fether brother-in-law
mother niece sister-in-law
son
husband stepfather
daughter Wife stepmother
brother fether-in-law stepbrother
sister mother-in-law stepsister
uncle son-in-law half-brother
aunt daughter-in-law half-sister
first cousin
All staff employees are requested to complete this
form and return it to the Budget officer
Approved
Richara A_ Sprague
I am not related
I am related by the
following relationship
4x6 02))
baua42tJ?)
Signature Employee Date
NW 88326
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nephew