Percy Smith JACKSON
age - 21
Home address - Purcellville Virginia
d.o.b. Aug 29 1895
where were you born? Lincoln Virginia
present occupation - barber
By whom employed? - McMullin (?)
where employed? Washington DC
Have you a father , mother, wife, child under 13 or a sister or a brother under 12 solely dependent on you for support? (specify which) none
married or single? married
Race - African
military service - none

Percy Smith Jackson (signature)