Moo/ 0 Current or former I.I. corrections K Assault on LI: corrections K Leadership mk O Ci /Describe below, El Current or runner intelligence K SAM subjr:ct or candidate K Separation weds ilktecrine Mott I K Other !Describe helm.; Title/Code TES Page I or 3 Form USM-312 Rev 11/17 EFTA0004

Last Name Current or former LE/corrections K Assault on LE/corrections K Leadership role K CI (Describe below) K Current or former intelligence K SAM subject or candidate K Separation needs (Describe below) K Other (Describe below) ASSOCIATES / CO-DEFENDANTS / RELATIVES CHILDREN SIGNIFICANT OTHE

rst, MI Current or former LE/corrections Assault on LE/corrections Leadership role CI (Describe below) Remark K Current or former intelligence K SAM subject or candidate K Separation needs (Describe below) K Other (Describe below) Date of Birth ASSOCIATES / CO-DEFENDANTS / RELATIVES / CHILDREN

or fonnerlAi'corrections K Assault on kfitorrections K Leadership role K CI (Describe befoul VIES Page I or3 O Current or limner intelligence K SAM subject or candidate O Separation needs rnesolhe halm) O other ilkscribt. liehnt.) Form USsa-312 Rev 11117 S0NY_GM_00173133 EFTA_00194788 EFTA