[104-10224-10012.pdf — page 197]
# HEATH BENEFITS REGISTRATION FORM(LOAL IMPLOSED MEALTH GENES ACT OF 1059)**PART A**FILL WHOREGISTER1. NAMELASTWIGROIFIRSTLeeMIDDLEH.2. Date Of Birth   MONTH DAY YEAR   12 1 19233. Are you married?   YesNo4. YOUR MAILING ADDRESS (NUMBER AND STREET)   15 Moda Street(CITY AND STATE)Fairfax, Virginia5. SEX   Male   Female6. Are you covered by or in any family member listed below cov- ered by or enrolling in, a plan under the Federal Employees Health Benefits Act of 1959 through the enrolment of another United States or District of Columbia Government employee or annuitant?   Place an 'X' in proper box to show your annual basic salary range.   Under $4,000   $5,000 to $9,999   $4,000 to $5,000   $10,000 or OverYesNo7. I elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity to cover my share of the cost of the enrollment. (Keep this information as requested below from inside cover of brochure of the plan you select).**PART B**FILL IN THISPART IF YOUWISH TO EN-ROLL IN AHEALTH BENEFITSPLAN.NAME OF PLANAssociation Benefit PlanOPTION (HIGH OR LOW)HighEnrollment Code Number4 2 22 In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age 17, including legally adopted children, and stepchildren and legitimate children who live with you in a regular parent-child relationship. Include also any unmarried child over age 19 who become disabled before age 19 and who, because of the disability, is incapable of self-support. (Attach a doctor's certificate for a disabled child age 19 or over.)NAMES OF FAMILY MEMBERSWife or HusbandEllen R. WigrenChristopher L. WigrenEric V. WigrenDATE OF BIRTH(Month, Day, Year)8/13/19273/10/19578/15/1959NAMES OF FAMILY MEMBERSDATE OF BIRTH**THIS PART MUSTALSO BE FILLEDIN IF YOUCHANGE YOURENROLLMENT.****PART C**FILL IN THISPART IF YOUWIS NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.3. If you are a female (employee or annuitant)-does the family listed above include a husband who is incapable of self-support by reason of mental or physical disability which can be expected to continue for more than one year? (If answer is "Yes," attach a doctor's certificate.)PLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 31. I elect not to enroll in any plan under the Health Benefits Act.3. The reason for my election is (Place an "X" in proper box):   (a) I am covered by a plan under the Health Benefits Act through the enrollment of my husband, wife, or parent.   (b) I am covered by a health insurance plan which is not under the Health Benefits Act.   (c) Any other reason.YESNO2. I elect to cancel my present enrollment under the Health Benefits Act.I elect to change my enrollment as shown by the enrollment number and other information in Part B.1. Enrollment code number of present plan.2. Number of event which permits change (See table on back of duplicate for proper number.)3. Date of event which permits change   MONTH DAY YEAR**PART D**FILL IN THISPART IF YOUWISH TOCHANGE YOURENROLLMENT.**PART E**ALL WHOREGISTERMUST FILLIN THIS PART.Lee H. Wigren June 24, 19601. NAME AND ADDRESS OF EMPLOYING OFFICE   WARNING.-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.)2. DATE RECEIVED IN EMPLOYING OFFICE   6/27/603. EFFECTIVE DATE OF ELECTION   7/1/604. PAYROLL OFFICE NO5. PAYROLL ACTION (INITIALS AND DATE)**PART F**TO BECOMPLETEDBYAGENCY.**REMARKS**(FOR USE ONLYBY ANNUITANTSAND AGENCY.)SATriplicate-To Employing Office101 08