CIA-RDP96-00788R001600120004-9

DATE
For use of this form, see AR 380-5; the proponent agency is the Office, Assistant Chief of Staff for Intelligence.
SECTION A - GENERAL
110:
FROM:
DATE RECEIVED
ACTION OFFICE(S)
SUSPENSE DATE(S)
REGISTER OR CONTROL NO.
CONTROL. LOG
OR FILE NO.
CLASSIFI-
CATION
NUMBER OF
COPIES
DESCRIPTION ( Type. File Ref .. Unclassified Subject
or Short Tule and Number of Indorsements/Incls)
DATE OF
DOCUMENT
ORIGINATOR
CL-007-83
S/NOFORN
1
Cy 1 of 2, Report CL-987/8210/01 W/1
EXHIBIT.
.NOTHING FOLOWS.
SECTION B - ROUTING
I ACKNOWLEDGE RECEIPT OF THE MATERIAL DESCRIBED HEREON
TC
COPY NO.
DATE
PRINTED NAME
SIGNATURE
2.
3
4.
5
SECHION C - DESTRUCTION CERTIFICATE (Check appropriate black)
MATERIAL DESCRIBED HEREON HAS BEEN:
PAGE OR COPY NO
3 DESTROYED
TORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER (AR 380-5)
OFFICE SYMBOL
DATE
PRINTED NAME OF CUSTODIAN OR REP
SIGNATURE
DESTRUCTION RECORD NO.
DATE
PRINTED NAME OF CERTIFYING/DESTR. OFF.
SIGNATURE
PAGE OR COPY NUMBER
DATE
PRINTED NAME OF WITNESSING OFFICIAL
SIGNATURE
SECTION D - REPRODUCTION AUTHORITY
NUMBER OF COPIES TO BE REPRODUCED
AUTHORIZED BY
DATE
SECTION E - RECEIPI/TRACER ACTION (Check appropriate block)
]RECEIPT OF DOCUMENT(S) ACKNOWLEDGED
DOCUMENTIS) HAVE NOT BEEN RECEIVED
TRACER ACTION: SIGNED RECEIPT FOR MATERIAL DESCRIBED ABOVE HAS NOT BEEN RECEIVED.
DATE
PRINTED NAME, GRADE OR TITLE
SIGNATURE
COMMENTS
DA FORM 3864, 1 Jul 79
EDITION OF 1 NOV 72 IS OBSOLETE.
D U.S.GPO:1990-0-319-060
Approved For Release 2000/08/08 : CIA-RDP96-00788R001600120004-9