of Birth (rnmidcVyyyy) 01/20/1953 16. Employer or School (if applicable) SOUTHERN TRUST COMPANY 18. Permanent Address: if P.O. Box is !Wed under Mailing Address Qriresdenbe is different from Mailing Address. Street/RFD a or URB (No P.O. Box) City Itene :kW 'VW( Apartmentlinit State Zip Code 19. Emergency Contact