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ICCLES
CCfcristjan name)
(Full namo cf nflieor to b<» typod or printed
in Una apace b j aunUiistmive omoo{
AFFIDAVIT TO BE EXECUTED BY CIVIL OFFICERS
OF THE "UNITED STATES UPON
APPOINTMENT TO OFFICE
Before me,
Standard Form No. 1041
Form approved by Comptroller General, U. b
December 27, ll'2f> (ivvisod)
Amended May 3,1040
(Title)
(Name)
personally appeared
(Address)
(Name)
who, being first duly sworn (affirmed), deposes and says: That he has been appointed to the office of a_-_
Member of the Board of Governors of the Federal Reserve System for a
(Name of office and place)
effective _
-
, 19
, by .thB..Presidjuat-.of.-tiie-IIniteA
(Name and title of appointing authority)
r
_Am£rjl-CA
_
and that neither he nor anyone/acting in his behalf has gitfefl, transferred,
promised, or paid any consideration for or in the expectationj^OTpe of receiving assistai^e yi seeding
lppotomw
A
"
SUBBCRIB^J^AND SWORN
CRIB^J^
' *
JQiU
(Signature of affiant
to (affirmed) before me this
[813 AL]
day of
GENERAL ACCOUNTING OFHCE, OFHCE OF THE COMPTROLLER GENERAL OF THE UNITED STATES
WASHINGTON, D. C.
SIB:
Receipt is hereby acknowledged of your affidavit under the act of December 11, 1926 (amended), re your
appointment as a civil officer of the United States effective
This rcctipt must b« submitted to the proper Disbursing
Officer or Disbursing Postmaster as his authority for making payment of salary.
, 19
Comptroller General of the United States.
By
System,
•lathi*
will All In hU B U M and UM mddr— to whleh hm wiah— r*c*ipt forwarded.
See
also instructions on reverse side hereof.'
Date stamp of G. A. O.
