[104-10225-10003.pdf — page 339]
# BENEFITS REGISTRATION FOREMPLOYEES HEALTH BENEFITS ACT OF 1959(Read Instructions on back of last page)1. (Use typewriter or ballpoint pen)   10741## PART AALL WHOREGISTERPICCOLO Joseph S.MUST FILE4. YOUR MAILING ADDRESS (NUMBER AND STREET)3. ARE YOU MARRIED?* YES [1]* NO [2]IN THIS3828 Garfield Street N.W. Washington 7, D.C.PART.6. Are you covered by or enrolling in, a plan under the Federal EmployeesHealth Benefits Act of 1959 (through the enrollment of anotherUnited States or District of Columbia Government employee orannuitant)?* YES []  NO [X]5. In proper box to show your annual basic salary   range.* UNDER $4,000 []* $6,000 TO $9,999 []* $4,000 TO $5,999 [X]* $10 000 OR OVER []1. 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. (Copy the information requested below from inside cover of brochure of the plan you select.)## PART BFILL IN THISNAME OF PLANPART IF YOUWISH TO EN-ROLL IN AASSOCIATION BENEFIT PLANHIGH4 2 1HEALTH BENEFITS2. In space below list all of eligible family members without exception. List your wife or husband first. Show your unmarried children underage 19, including legally adopted children, and stepchildren and also, include those children who are not themselves employees or annuitants if aself-support. (Attach a doctor's certificate for a disabled child age 19 or over.)If enrollmentInclude also any unmarried child over 19 who becomes disabled before age 19 and who, because of the disability, is incapable ofis for self only,answer item 1.NAMES OF FAMILY MEMBERSDATE OF BIRTHNAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)If enrollmentis for self and[1][6]family, alsoanswer item 2and item 3 if[2][7]applies.[3][8][4][9][5][10]3. If you are a female (employee or annuitant)--does the family listed above include a husband who is incapable of selfTHIS PART MUSTsupport by reason of mental or physical disability which can be expected to continue for more than one year? (If answerALSO BE FILLEDis "Yes," attach a doctor's certificate.)* YES [] NO []  IN IF YOU  CHANGE YOUR  ENROLLMENT.  PLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3## PART C1. I elect not to enroll in any plan3. The reason for my election is (Place an "X" in proper box)   FILL IN THIS   (a) I am covered by a plan under the Health Benefits Act through the enrollment   of my husband, wife, or parent.   PART IF YOU* []  under the Health Benefits Act.  DO NOT TO  ENROLL OR IF  (b) I am covered by a health insurance plan which is not under the Health  TOO WISH TO2. I elect to cancel my present enroll-   Benefits Act.   CANCEL YOUR   ment under the Health Benefits Act.* []  ENROLLMENT.  (c) Any other reason.* []## PART DI 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.   FILL IN THIS   See table on back of duplicate for proper number.3. Date of event which permits change   PART IF YOU   WISH TO   MONTH   DAY   YEAR   CHANGE YOUR   ENROLLMENT.   WARNING.--Any intentional false statement in   this application or willful misrepresentation relative## PART Ethereto is a violation of the law punishable by afine of not more than $10,000 or imprisonment ofALL WHOnot more than 5 years, or both. (18 U.S.C 1001.)REGISTERMUST FILEIN THIS PART.2. DATE RECEIVED IN   EMPLOYING OFFICE   28 June 19603. EFFECTIVE DATE OF   ELECTION## PART FTO BECOMPLETED1. NAME AND ADDRESS OF EMPLOYING OFFICE4. PAYROLL OFFICE (File No)5. PERSONNEL ACTION   (INITIAL AND DATE)   BY   AGENCY.   REMARKS   FOR USE ONLY   BY ANNUITANTS   AND AGENCY   (SIGNATURE OF AUTHORITY AGENCY OFFICIAL)   Triplicate-To Employing Office   APRIL 1960