Francesco/who-killed-jfk huggingface dataset:
[104-10225-10003.pdf — page 324]
SECRET3. Travel to your post of duty overseas and your return travel to the United States, as well as travel performed overseas which is consistent with your cover designation, will normally be at the direction of your cover facility. Such travel will be accomplished in conformance with applicable regulations of your cover facility except when you are directed for operational reasons to perform travel in accordance with the regulations of this organization.4. Salary and (except as provided in paragraph three (3) above) allowances paid by your cover facility shall be retained by you to the extent that they are less than or equal to the salary and allowance paymenta due on the basis of your grade level with this organization. If such cover payments are less than the shount due, the difference will be credited to your payroll. account with this organization. If such cover payments exceed the amount due, the overage will be remitted to this organization at designated intervals, presently   Computations hereunder will be made on the basis of the aggregate gross due and received provided, however, that in computing remittances for overage Federal and, if applicable, District of Columbia income taxes withheld by your cover facility against the overage may be deducted. To assure timely accuracy in your payroll account with this organization you are expected to immediately report cover facility payroll changes.5. Your status as an employee of this organization will continue in full force and effect during your period of duty with your cover facility and you will continue to be entitled to all rights, benefits and emoluments of such status. Certain variations in procedure will be required, however, to preserve the security of your cover position.a. Upon integration into your cover facility, you will continue to be covered by the provisions of the Civil Service Retirement Act, as amended, and at your personal expense you will be subject to payroll deductions for retirement purposes (now six and one-half per cent) on the basis of your cover salary or your salary from this organization, whichever is the greater.b. If you receive taxable income from both your cover facility and this organization, necessary adjustments for Federal, and if applicable, District of Columbia income tax purposes will be made in conformance with instructions received from this organization.c. Consistent with your cover activity, you will continue to be responsible for compliance with the rules and regulations of this organization.d. You are not assured upon the completion of your period of duty with your cover facility of any status with your cover based on your services performed with that organization at the request of this organization.2SECRET
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# SECRETe. All annual and sick leave which is accrued to your credit at the time of integration will be transferred to your cover facility. While integrated you will be permitted annual leave, sick leave, home leave, and leave without pay in accordance with the regulations of your cover facility in lieu of the leave benefits of this organi- zation. Upon completion of your integration your accrued annual and sick leave will be transferred to your credit with this organization. If security conditions require that your cover facility make a lump- sum payment for accrued annual leave, you will be required to pay the gross amount thereof to this organization including any income taxes withheld by your cover facility.6. You will be required to keep forever secret this agreement and all other information which you may obtain by reason hereof, unless you are released in writing by this organization from this obligation. Violation of such secrecy my subject you to criminal prosecution under the Espionage Lavs, dated 25 June 1948, as amended, and other applicable lava and regulations. The termination of your employment with this organization will not release you from the obligation of any security oath you may be required to take.UNITED STATES GOVERNMENT![signature]BYFersonnel OfficeACCEPTED:![signature]3Form 15350 Obsolete Previous SECRET (4-12)9-60 Edition
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CONFIDENTIAL(When Filled In)IMPORTANTCentral Processing Branch has been charged with responsibility (OPM 20.5.1 dated 12 October 1961) for ensuring that all employees process, PCS to the free reviewed the field version of the Employee Conduct Handbook. You will not be checked-out for your proposed travel until you sign the following statement and return it to CPB. Your Personnel Officer can provide you with a copy of the Handbook.MEMORANDUM OF UNDERSTANDINGI hereby acknowledge that I have read and understand the contents of Field Handbook 20-4, Employee Conduct, dated 30 July 1962![signature]SignatureJOSEPH PICCOLO![date]
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SECRET(When Filled In)VERIFIED RECORD OF OVERSEAS SERVICETO: Office of Personnel, Statistical Reporting Branch, ROOM S S Seadquarters| EMPLOYEE SERIAL NO. | NAME OF EMPLOYEE   | OFFICE/COMPONENT || ------------------- | ------------------ | ---------------- || 1-6                 | LAST (Print)       |                  || 025658              | PICCOLO, JOSEPH S. | 57               |INSTRUCTIONSUSE APPROPRIATE SPACE BELOW TO REPORT DATA FOR EITHER PCS OR TOY. INSERT APPROPRIATE CODE NUMBER IN "CODE" COLUMNTO DESIGNATE WHETHER SUBMISSION IS OF BASIC DATA, CORRECTION, OR CANCELLATION (Une only). REPORT DATES BY USING THENUMBER FOR THE MONTH, AND LAST TWO DIGITS ONLY FOR YEAR.PCS DATES OF SERVICE| TYPE OF DATA    | CODE | ARRIVAL             | DEPARTURE           | COUNTRY     | OMIT  || --------------- | ---- | ------------------- | ------------------- | ----------- | ----- ||                 |      | MONTH  DAY YEAR     | MONTH  DAY YEAR     |             |       || 1. PCS (Basic)  | 27   | 28-29  30-31  32-33 | 34-35  36-37  38-39 |             | 40-42 || 3. CORRECTION   |      |                     |                     |             |       || 5. CANCELLATION | 1    | 09 29 65            |                     | MEXICO CITY | 4/50  |TDY DATES OF SERVICE| TYPE OF DATA    | CODE | DEPARTURE           | RETURN              | AREA(S) | OMIT  || --------------- | ---- | ------------------- | ------------------- | ------- | ----- ||                 |      | MONTH  DAY YEAR     | MONTH  DAY YEAR     |         |       || 2. TDY (Basic)  | 27   | 28-29  30-31  32-33 | 34-35  36-37  38-39 |         | 40-42 || 4. CORRECTION   |      |                     |                     |         |       || 6. CANCELLATION |      |                     |                     |         |       |SOURCE OF RECORD DOCUMENT| TRAVEL VOUCHER  | X DISPATCH                                || --------------- | ----------------------------------------- || CABLE           | DUTY STATUS OR TIME AND ATTENDANCE REPORT || OTHER (Specify) |                                           || DOCUMENT IDENTIFICATION NO. | DOCUMENT DATE/PERIOD || --------------------------- | -------------------- || HDQT-5946                   | 7 OCTOBER 1965       |REMARKS| PREPARED BY | X REPORT ANNOTATED ON SOURCE DOCUMENT || ----------- | ------------------------------------- ||             | DATE 10/19/65                         ||             | SIGNATURE                             |SECRET
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# SECRET(When Filled In) 623751 NOV 1965# VERIFIED RECORD OF OVERSEAS SERVICETO: Office of Personnel, Statistical Reporting Branch, ROOM 5 E 2506 Headquarters| EMPLOYEE SERIAL NO. | NAME OF EMPLOYEE | OFFICE/COMPONENT || ------------------- | ---------------- | ---------------- ||                     | LAST             |                  || 1-6                 | (Print)          |                  || 125658              | PICCOLO,         | 57               ||                     | Joseph           |                  |INSTRUCTIONSUSE APPROPRIATE SPACE BELOW TO REPORT DATA FOR EITHER PCS OR TOY. INSERT APPROPRIATE CODE NUMBER IN "CODE" COLUMN TO DESIGNATE WHETHER SUBMISSION IS OF BASIC DATA, CORRECTION, OR CANCELLATION (One only). REPORT DATES BY USING THE NUMBER FOR THE MONTH, AND LAST TWO DIGITS ONLY FOR YEAR.|                 |      |         | PCS DATES OF SERVICE |         |       |       |       |     |       || --------------- | ---- | ------- | -------------------- | ------- | ----- | ----- | ----- | --- | ----- || TYPE DATA       |      | ARRIVAL | DEPARTURE            | COUNTRY | OMIT  |       |       |     |       ||                 | CODE | MONTH   | DAY                  | YEAR    | MONTH | DAY   | YEAR  |     | 40-42 || 1. PCS (Basic)  | 27   | 28-29   | 30-31                | 32-33   | 34-35 | 36-37 | 38-39 |     |       || 3. CORRECTION   |      |         |                      |         |       |       |       |     |       || 5. CANCELLATION |      |         |                      |         |       |       |       |     |       ||                |      |           | TDY DATES OF SERVICE |         |       |     |      |     |       || -------------- | ---- | --------- | -------------------- | ------- | ----- | --- | ---- | --- | ----- || TYPE DATA      |      | DEPARTURE | RETURN               | AREA(S) | OMIT  |     |      |     |       ||                | CODE | MONTH     | DAY                  | YEAR    | MONTH | DAY | YEAR |     | 49-42 || * TDY (Basic)  | 27   | 14        | 15                   | 65      | 11    | 165 |      | WH  | 811   || * CORRECTION   |      |           |                      |         |       |     |      |     |       || * CANCELLATION |      |           |                      |         |       |     |      |     |       |* TRAVEL VOUCHERCABLEOTHER (Specify)SOLACE OF RECORD DOCUMENTDISPATCHDOCUMENT IDENTIFICATION NO.DUTY STATUS OR TIME AND ATTENDANCE REPORTDOCUMENT DATE/PERIODREMARKS![document identifier]![handwriting text]![stamped text]SECRET![illegible signature]
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# CONFIDENTIALComplete in duplicate. The data recorded on this formis essential in determining travel expenses allowable in connection with leave at government expense, overseas duty, return to residence upon separation, and for providing current residence and dependency information required in the event of an employee emergency. The original of this form will be filed in the employee's official personnel folderNAME OF EMPLOYERPiccoloSOCIAL SECURITY NUMBER265-44-1914## RESIDENCE DATAPLACE OF RESIDENCE WHEN INITIALLY EMPLOYED BY AGENCY.Washington D.C.LAST PLACE OF RESIDENCE IN CONTINENTAL U.S. (Il appointed abroad)Washington D.C.PLACE IN CONTINENTAL U.S. DEDIGNATED AS PERMANENT RESIDENCEFt. Lauderdale, Fla.HOME LEAVE RESIDENCEFt. Lauderdale, Fla.SINGLEMARITAL STATUSMARRIEDSEPARATEDDIVORCEDWIDOWEDANNULLEDDATE OF MARRIAGEIF MARRIED, PLACE OF MARRIAGEDATE OF DECREEIF DIVORCED, PLACE OF DIVORCE DECREEDATE SPOUSE DIEDIF WIDOWED, PLACE SPOUSE DIEDIF PREVIOUSLY MARRIED, INDICATE NAME(S) OR SPOUSE, REASON(S) FOR TERMINATION, AND DATE(S)## MEMBERS OF FAMILYNAME OF SPOUSEN/AADDRESSTELEPHONE NO.NAMES OF CHILDRENN/AADDRESSSEXDATE OF BIRTHNAME OF YOUR FATHER (Or male guardian)Joseph PiccoloADDRESSFt. Lauderdale, Fla.TELEPHONE NO.LO4-5834NAME OF YOUR MOTHER (Or female guardian)Irene D. PiccoloADDRESSFt. Lauderdale, Fla.TELEPHONE NO.LO 4-5834WHAT MEMBRIS) OF YOUR FAMILY IF ANY, HAS BEEN TOLD OF YOUR AFFILIATION WITH THE ORGANIZATION IF CONTACT IS REQUIRED IN AN EMERGENCY.Parents## PERSON TO BE NOTIFIED IN CASE OF EMERGENCYNAMEPiccolo Irene A.RELATIONSHIPMotherHOME ADDRESS1636 N.E. 20th. St. Ft. Lauderdale, FlaHOME TELEPHONE NUMBERLO 4-5834BUSINESS ADDRESSN/ABUSINESS TELEPHONE & EXTENSIONN/AIS THE INDIVIDUAL NAMED ABOVE WITTING OF YOUR AGENCY APPILIATION? (If "No" give name and address of organization he believes you owe fee.)NOIS THIS INDIVIDUAL AUTHORIZED TO MAKE DECISIONS ON YOUR BEHALF IN THE EVENT YOU ARE INCAPABLE? (If "No" give name and address of person, if any, who can make such decisions in case of emergency.)NODOES THIS INDIVIDUAL KNOW THAT HE HAS BEEN DESIGNATED AS YOUR EMERGENCY ADDRESSEE? (If answer is "No" explain why in item 6.)NOThe persons named in item 3 above may also be notified in case of emergency. IF SUCH NOTIFICATION IS NOT DESIRABLE BECAUSE OF HEALTH OR OTHER REASONS, PLEASE SO STATE IN ITEM 6 ON THE REVERSE SIDE OF THIS FORM.CURRENT RESIDENCE AND DEPENDENCY REPORTCONFIDENTIAL
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CONFIDENTIAL(When Filled In)VOLUNTARY ENTRIESExperience in the handling of employee emergencies has shown that the absence of certain personal data often delays and complicates the settlement of estate and financial matters. The information requested in this section may prove very useful to your family or attorney in the event of your disability or death and will be disclosed only when circumstances warrant.INDICATE NAME AND ADDRESS OF ANY BANKING INSTITUTIONS WITH WHICH YOU HAVE ACCOUNTS AND THE NAMES IN WHICH THE ACCOUNTS ARE CARRIED.FT. LAUDERDALE NATIONAL BANK (Checking & Savings)FT. LAUDERDALE, FLORIDAJoseph Stephen PiccoloARE YOU A MEMBER OF THE NORTHWEST FEDERAL CREDIT UNION?  ☑ YES ☐ NOIF YES, DO YOU HAVE A JOINT ACCOUNT? ☐ YES ☑ NOHAVE YOU COMPLETED A LAST WILL AND TESTAMENT? ☑ YES ☐ NO. (If "Yes" where is document located?)With Parents.HAVE YOU PREPLANNED AN ARRANGED GUARDIANSHIP OF YOUR CHILDREN IN CASE OF COMMON DISASTER TO BOTH PARENTS?☐ YES ☑ NO. (If "Yes" give name(s) and address)N/AHAVE YOU EXECUTED A POWER OF ATTORNEY? ☐ YES ☑ NO. (If "Yes", who possess the power of attorney?)ADDITIONAL DATA AND/OR CONTINUATION OF PRECEDING ITEMSSIGNED ATDATESIGNATURE27 Oct 65CONFIDENTIAL
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# NOT OF CHANGE IN HEALTH BENEFITS ENDMENTFEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1## A. IDENTIFYING DATA1. NAME (LAST) (FIRST) (MIDDLE INITIAL) 2. DATE OF BIRTH 3. CASE ( CONTROL NO)Piccolo, Joseph 12/8/35 098694. ADDRESS (NUMBER AND STREET) 5. PAYROLL OFFICE NO. 6. ENROLLMENT CODE NO1123991 421(CITY AND ZONE NUMBER) (STATE) 7. DATE ACTION ALLOWED EFFECTIVE8/3/62## B. TERMINATIONENROLLMENT TERMINATES EFFECTIVE ON THE DATE SHOWN IN ITEM 7. ABOVE, WITH ELIGIBILITY TO CONVERT TO A NONGROUP CONTRACT.## C. CHANGE IN PLANENROLLMENT SHOWN BY ITEM 6. ABOVE, HAS BEEN TERMINATED BECAUSE OF ELECTION OF ANOTHER PLAN.## D. TRANSFER OUT## E. TRANSFER INNAME AND ADDRESS OF NEW PAYROLL OFFICE (OR ENROLLMENT ACCEPTED BY THIS AGENCYRETIREMENT SYSTEM) TO WHICH TRANSFERRING## F. SUSPENSIONENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON DATE SHOWN IN ITEM 7. ABOVE WHILE ENROLLEE IS ON ACTIVE MILITARY DUTY OR FOR THE REASON STATED IN REMARKS## G. REINSTATEMENTENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON DATE SHOWN IN ITEM 7, ABOVE. [X]## H. CHANGE IN NAME OF ENROLLEEENROLLMENT HAS BEEN CHANGED TO.NAME ADDRESS ID DIFFERENT FROM ITEM 4 ABOVE DATE OF BIRTH## I. CHANGE IN ENROLLMENT - SURVIVOR ANNUITANTENROLLMENT HAS BEEN CHANGED FROM FAMILY COVERAGE TO SELF ONLYNEW ENROLLMENT CODE NUMBER## J. REMARKS11505510141## K. DATE OF NOTICE8/7/63![signature of health benefits officer]HEALTH BENEFITS OFFICERCentral Intelligence AgencyWashington 25, D.C.QUADRUPLICATE
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SECRETMILITARY STATUS QUESTIONNAIRE1. THIS DATE (Month-day-year)AUGUST 27, 1967.2. NAME (Last-first-middle)Diccolo, Joseph Stephan3. DATE OF BIRTH (Month year)Dec 19354. SEXMALE5. OFFICE TO WHICH ASSIGNED6. SCHEDULE AND GRADE65-77. SUBJECT TO CURRENT DRAFTNO8. INDICATE DRAFT CLASSIFICATION, IF ANY1-DVETERANS COMPLETE THE FOLLOWING9. BRANCH OF SERVICE ON SEPARATION (Check one)(4) AIR FORCE10. MILTORADE ON SEPARATIONSTAFF SERCIAN!10A. YRS/MOS OF ACTIVE SERVICELYRIme11. STATUS AT TIME OF SEPARATION (Check one)(2) RESERVE12. TYPE OF SEPARATION (Check one)PLEASE NOTEALTHOUGH YOU MAY HAVE A SERVICE CONNECTED DISABILITY, DO NOT CHECK THE BOX "RETIRED-SERVICE CONNECTED DISABILITY" UNLESS YOU WERE ACTUALLY RETIRED FOR THIS REASON. IF OTHERWISE, CHECK "HONORABLE DISCHARGE" OR "RELEASED TO INACTIVE DUTY" AS APPROPRIATE, EVEN THOUGH YOU MAY BE DRAWING A DISABILITY ALLOWANCE OR COMPENSATION.(1) RELEASED TO INACTIVE DUTY(2) HONORABLE DISCHARGE(3) METIREO-20 (or more) YRS, SERVICE(4) RETIRED-LESS THAN 20 YRS SORVICE(8) OTHER-SPECIFY UNDER COMMENTSMEMBERS OF RESERVE FORCES COMPLETE THE FOLLOWING13. RESERVE BRANCH OR SERVICED.C. AR NAT'L Guard14. ORIGINAL ENTHY DATE IN ARMED SERVICES13 FeB 5415. SERVICE SERIAL NO.4777891416. MOS, APSC, DESIGNATOR, OR RATING7075017. MIL. ORADESSGT18. RESERVE CATEGORY (Check ane)(1) READY19. EXPIRATION DATE OF APPOINTMENT OR ENLISTMENT (Munth and year)Aug 196320. MIL. MOBILIZATION ASSIONMENT221. RESERVE UNIT TO WHICH ASSIGNED OR ATYACHRO121ST TAC FTR SQ Andrews AFB77. COMMENTSItem 12, Honorable Separation From Active Duty USAT to Active Reserve DCANG. 24 Aug 62,DO NOT WRITE IN SPACES BELOWSERIAL NUMBER025658NAMEDOB12-35SEXOFFICE CODE61SCHD GR.US 07DRAFT STATUSCLASS.1-DBRANCH SERVICE MIL. GRADE/ E-5STATUS AT SEPARATION2TYPE OF SEPARATION(A-leas than 8 yea; 3-8 yrs or more)1 A 3 A 5 A 701 B 3 B 5 B2 A 4 A 6 A2 B 4 B 6 B 8 BBRANCH SERVICE ENTRY DATE8 09/4SERV. SER. NO. MOS, APSC,70750MIL. GRADE CATEGORY68-71. EXPIRATION DATE6 6MOBILIZATION ASSIGNMENT213. ASSIGNMENT UNITMOBILIZATION CATEGORT2SECRET
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# APPOINTMENT AFFIDAVITSIMPORTANT.---Before swearing to these appointment affidavits, you should read and understand the attached information for appointeeCENTRAL INTELLIGENCE AGEZICY(Deperiment or agency)LANGLEY, VIRGINIA(Place of employment)I. JOSEPH L. PICCOLO, do solemnly swear (or affirm) that-## A. OATH OF OFFICEI will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely without any mental reservation or purpose of evasion; that I will well and faithfully discharge the duties of the office on which I am about to enter, SO HELP ME GOD.## B. AFFIDAVIT AS TO SUBVERSIVE ACTIVITY AND AFFILIATIONI am not a Communist or Fascist. I do not advocate nor am I knowingly a member of any organization that advocates the overthrow of the constitutional form of the Government of the United States, or which seeks by force or violence to deny other persons their rights under the Constitution of the United States. I do further swear (or aftirm) that I will not so advocate, nor will I knowingly become a member of such organization during the period that I am an ein-ployee of the Federal Government or any agency thereof.## C. AFFIDAVIT AS TO STRIKING AGAINST THE FEDERAL GOVERNMENTI am not participating in any strike against the Government of the United States or any agency thereof, and I will not so participate while an employee of the Government of the United States or any agency thereof. I do not and will not assert the right to strike against the Govern. ment of the United States or any agency thereof while an employee of the Government of the United States or any agency thereof. I do further swear (or affirm) that I am not knowingly a member of an organization of Government employees that asserts the right to strike against the Government of the United States or any agency thereof and I will not, while an employee of the Government of the United States or any agency thereof, knowingly become a member of such an organization.## D. AFFIDAVIT AS TO PURCHASE AND SALE OF OFFICEI have not, nor has anyone acting in my behalf, given, transferred. promised or paid any con-sideration for or in expectation or hope of receiving assistance in securing such appointment.## E. AFFIDAVIT AS TO DECLARATION OF APPOINTEEThe answers given in the Declaration of Appointee on the reverse of this form are true and correct.25 August 1962...Subscribed and sworn before me this 27th day of August A. D. 1967.at Langley VirginiaDavid W HaberPersonnel ClerkNOTE - The oath of office must be administered by a person specified in 5 U. S. C. 16, or by a person designated to administer oaths under section 486, A. t of June 26, 1943, 5 U S C. 16a II he a Notary Public, the date of expiration of his commission should be shown.
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CONFIDENTIAL(when filled in)ACKNOWLEDGEMENTI hereby acknowledge that I have read and understand the contents of Handbook 20-4, Employee Conduct, dated 29 August 1961.![signature]Signature![date] 27 August 1962DateCONFIDENTIAL
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SECRET(When Filled In)# VERIFIED RECORD OF OVERSEAS SERVICETO: Office of Personnel, Statistical Reporting Branch, ROOM 192 Curie Hall|                     || ------------------- || EMPLOYEE SERIAL NO. || 1-6                 || 25638               || NAME OF EMPLOYEE || :--------------: ||  LAST   (Print)  ||       7-18       ||     Piccolo      || FIRST || :---: || Fazer || MIDDLE || :----: ||   5    || OFFICE/COMPONENT || :--------------: ||      25-26       ||        46        |INSTRUCTIONSUSE APPROPRIATE SPACE BELOW TO REPORT DATA FOR EITHER PCS OR TDY. INSTAT APPROPRIATE CODE NUMBER IN "CODE" COLUMN TO DESIGNATE WHETHER SUBMISSION IS OF BASIC DATA, CORRECTION, OR CANCELLATION (One only). REPORT DATES BY USING THE NUMBER FOR THE MONTH, AND LAST TWO DIGITS ONLY FOR YEAR.| TYPE OF DATA    | CODE | MONTH 28-29 | DAY 30-31 | YEAR 32-33 | MONTH 34-35 | DAY 36-37 | YEAR 38-39 | COUNTRY | OMIT || --------------- | ---- | :---------: | :-------: | :--------: | :---------: | :-------: | :--------: | ------- | ---- || 1. PCS (Basic)  | 1    |             |           |            |     01      |    18     |     60     | Mexico  | 450  || 3. CORRECTION   |      |             |           |            |             |           |            |         |      || 5. CANCELLATION |      |             |           |            |             |           |            |         |      || TYPE OF DATA    | CODE | MONTH 28-29 | DAY 30-31 | YEAR 32-33 | MONTH 34-35 | DAY 36-37 | YEAR 38-39 | AREA(S) | OMIT || --------------- | ---- | :---------: | :-------: | :--------: | :---------: | :-------: | :--------: | ------- | ---- || 2. TDY (Basic)  |      |             |           |            |             |           |            |         |      || 4. CORRECTION   |      |             |           |            |             |           |            |         |      || 6. CANCELLATION |      |             |           |            |             |           |            |         |      |SOURCE OF RECORD DOCUMENT| TRAVEL VOUCHER              | DISPATCH                                  || --------------------------- | ----------------------------------------- || CABLE                       | DUTY STATUS OR TIME AND ATTENDANCE REPORT || OTHER (Specify) X-File      |                                           || DOCUMENT IDENTIFICATION NO. | DOCUMENT DATE PERIOD                      || PTLN-Roseph                 | 25 Jan 60                                 || REMARKS                     |                                           |![signature]
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TILE OF CHAT IN REIMBURSEMENT SLIP 10![unclear text image]A. IDENTITY DATA![unclear text image]7-30 81B. TERMINATION![unclear text image]C. CHANGE IN PLANYOUR PAYMENT SHOWN BY ITEM 6, ABOVE, FOR EACH BENEFICIARY IN ACCORDANCE WITH YOUR RECENT ELECTION (S)AFFECTS PLAN.D. TRANSFERYOUR IMPRONEMENT IN A HEALTH BENEFITS PLAN THAT WILL A TRANSFER TO![unclear text image]![unclear text image]YOUR ENROLLMENT IN A HEALTH BEN. PLAN HAD RECIEVED TO ANOTHER.E. SUSPENSION OR REINSTATEMENT![unclear text image]YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN, SEES SUCH AS YOU ARE ON ACTIVE DUTY OR HAVEBEEN RELEASED TO THE RESERVAYOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN REINSTATED, EFFECTIVE ON DATE SHOWN IN ITEM 7, ABOVE.F. CHANGE IN NAME OF ENROLLEE![unclear text image]THE DOCUMENT SHOWN IN PART A, ABOVE, HAS BEEN CHANGED TO![unclear text image]![unclear text image]![unclear text image]G. CHANGE IN ENROLLMENT - SURVIVOR ANNUITANT![unclear text image]YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN CHANGED TO SIRV.FAMILY COVERAGE TO SELF ONLY.![unclear text image]NEW ENROLLMENTCODE NUMBERH. REMARKS117417-16-82I. DATE OF NOTICE![unclear signature]HEALTH BENEFITS OFFICER(ALTERNATE) NAME OF AGENCYADDRESS![unclear text image]QUADRUPLICATE