[104-10224-10008.pdf — page 33]
# ANNUITY WITH SURVIVOR BENEFIT TOWIDOW OR WIDOWERSPECIFY THE PORTION OF YOUR ANNUITY YOU WISH USED AS THE BASEFOR YOUR WIDOW'S (OR WIDOWER'S) SURVIVOR ANNUITY*   If you want all your annuity used as the base for the survivor benefit, write the word "ALL" in the box below. If you want only part of your annuity used as the base for the survivor benefit, write the yearly amount of your annuity you want used.$ ______THE SURVIVOR'S ANNUITY WILL BE 55% OF ALL OR WHATPORTION OF YOUR ANNUITY YOU SPECIFY AS THE BASEFOR HIS (OR HER'S) BENEFIT*   If you survive this annuity, you will receive this type of annuity unless you chose the annuity in I.2.*   The annuity payable to you during your lifetime will be much of any amount up to $3,600 a year as is needed to provide for base benefit, plus 10% of any amount over $3,600 will be used.*   If you retire for total disability before age 60 and yet a "regular" annuity as the base for this survivor annuity, the extra amount which may be payable to make up the prescribed minimum annuity.*   If your wife (or husband) should die before you, no change in type of annuity will be permitted, your annuity will not be increased, nor may you name any other person as survivor.*   The survivor's annuity will begin upon your death and end when she (or he) dies or remarries.---# ANNUITY WITHOUT SURVIVOR BENEFIT(I do not desire my wife (or husband) to receive a survivor annuity benefit after my death.)*   If you choose this type, your wife (or husband) cannot be paid a survivor annuity after your death.*   This type provides annuity payments to you only.---# TYPES OF ANNUITY: UNMARRIED APPLICANTS ONLY (Including Widowed and Divorced)# ANNUITY WITHOUT SURVIVOR BENEFIT*   If you are not married, you will receive this type of annuity unless you choose the annuity in G.2*   This type provides annuity payments to you only---# ANNUITY WITH SURVIVOR BENEFIT TONAMED PERSON HAVING AN INSURABLEINTERESTSPECIFY THE NAME, RELATIONSHIP AND DATE OF BIRTH OF THE PERSON YOU WISHTO RECEIVE THE SURVIVOR ANNUITYNAME OF PERSON (First, middle, last)RELATIONSHIP _______ DATE OF BIRTH (Mo., day, yr.) _______SEE UNMARRIED EMPLOYEE UNDER INFORMATION REGARDING SURVIVORANNUITIES ON THE ATTACHED INFORMATION SHEET FOR EXPLANATION OF REDUC-TIONS IN YOUR ANNUITY.*   This type is available to all retiring unmarried employees who are in good health.*   It provides a reduced annuity to you and a survivor annuity to the person named as having an insurable interest.*   The survivor's annuity will begin upon your death and end when she (or he) dies.*   The survivor's annuity will be 55% of the reduced annuity you receive.*   If you choose this type, you will have to undergo a medical examination which will be arranged by the Director of Personnel at no cost to you.*   If the person named as having an insurable interest should die before you, no change in type of annuity will be permitted, your annuity will not be increased, nor may you name any other person as survivor.---# CERTIFICATION OF APPLICANTWARNING - Any intentional false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both (18 U.S.C. 1001)I hereby certify that all statements made in this application are true to the best of my knowledge and beliefSee Attached Memo dated31 July 1979---# FOR OFFICE OF PERSONNEL USE ONLYSECRET