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# HEALTH BENEFITS REGISTRATION FORMFEDERAL EMPLOYEES MERLIN BENT PROGRAMTO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL NUMBER IF ELECTION IS TO CANCEL ENROLLMENT ORNEW ONE TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN# PART AALL WHO REGISTER MUST FILL IN THIS PART.1. NAMEPiccolo Joseph4. YOUR MAILING ADDRESS5. DATE OF BIRTHMONTH 12 DAY 8 YEAR 35IMPORTANTIT IS ILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF YOU ARE ALREADY COVERED THROUGH THEFAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER ENROLLMENTIS CANCELLED OR CHANGED TO SELF ONLY. SIMILARLY, IF A FAMILY MEMBER COVERED UNDER THIS PART IS COVERED THROUGH HIS (OR HER) OWN ENROLLMENT, YOUCANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT# PART B1. I elect to enroll in a health benefits plan as shown below. I authorize deductions from my salary, compensation, or annuity to cover my share of the cost   of the enrollment (Copy the information requested below from back page of the plan you select.)FILL IN THIS PART IF YOUWISH TO ENROLL OR CHANGEYOUR ENROLLMENT IN AHEALTH BENEFITS PLAN.NAME OF PLANOPTION (HIGH OR LOW)ENROLLMENT CODE NUMBER2. In space below list all eligible family members without exception; list your wife or husband first, then your unmarried children under age 22, including   (a) legally adopted children and (b) stepchildren, foster children, and illegitimate children who live with you in a regular parent-child relationship.   Include also any unmarried child over 21 who became disabled before age 21 and who, because of the disability, is incapable of self-support. Attach   a doctor's certificate for a disabled child age 21 or over if one is not already on file. DO NOT LIST PARENTS OR OTHERS WHO ARE NOT   ELIGIBLE FAMILY MEMBERS. THEY WILL NOT RECEIVE BENEFITS, EVEN IF THEY ARE DEPENDENT ON YOU AND ARE LISTED.If enrollment is for self only; answeritem 1. If enrollment is for self andfamily, also answer item 2.| NAMES OF FAMILY MEMBERS | DATE OF BIRTH (Month, Day, Year) |     | NAMES OF FAMILY MEMBERS | DATE OF BIRTH (Month, Day, Year) || ----------------------- | -------------------------------- | --- | ----------------------- | -------------------------------- || Wife or Husband Norma E | Oct 29, 43                       |     |                         |                                  ||                         |                                  |     |                         |                                  ||                         |                                  |     |                         |                                  ||                         |                                  |     |                         |                                  ||                         |                                  |     |                         |                                  |IF YOU ARE CHANGING YOURENROLLMENT ALSO FILL INPART D.# PART CFILL IN THIS PART IF YOUWISH NOT TO ENROLL OR IFYOU WISH TO CANCEL YOURENROLLMENT.PLACE AN 'X' IN ITEM 1 OR 2, WHICHEVER APPLIES.1. I ELECT NOT TO ENROLL IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS ACT.2. I ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THE CODE   NUMBER SHOWN BELOW.Present Enrollment Code Number# PART DFILL IN THIS PART, AS WELLAS PART B, TO CHANGE YOURENROLLMENT.ANSWER ITEMS 1, 2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE.1. ENROLLMENT CODE NUMBER OF PRESENT PLAN4212. NUMBER OF EVENT WHICH PERMITS CHANGE. (See table on back of duplicate for proper number)23. DATE OF EVENT WHICH PERMITS CHANGEMONTH 2 DAY 14 YEAR 67WARNING.-Any intentional false statement in this application or willful misrepresentationrelative 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.)# PART EALL WHO REGISTER MUST FILL IN THIS PART.(YOUR SIGNATURE-DO NOT PRINT)(DATE)# PART FTO BE COMPLETED BY AGENCY.1. NAME AND ADDRESS OF EMPLOYING OFFICE.S OFFICER(ALTERNATE)2. DATE RECEIVED IN EMPLOYING OFFICE 1-17-64. PAYROLL OFFICE NO.3. EFFECTIVE DATE OF ELECTION 2-12-175 SF 2811 REPORT NO.(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)REMARKSFOR USM ONLYDuplicate - to Employing Office