[104-10291-10004.pdf — page 263]
# ALTH BENEFITS REGISTRATION FOR 3367FEDERAL EMPICITEES HEALTH BENEFITS ACT OF 1959(See instructions on back of last page)(Use only typewriter or ball point pen)**PART A**FILL THISREGISTERPOST FILEIN THISPART.1. NAME   Windy Travis4. YOUR MAITAL ADDRESS   (NUMBER AND STREET)6. Are you covered by, or is any family member listed below cov-   ered by or enrolling in, a plan under the Federal Employees   Health Benefits Act of 1959 (through the enrollment of another   United States or District of Columbia Government employee or   annuitant)?YES [x] NO [ ]**PART B**FILL IN THISPART IF YOUWISH TO EN-ROLL IN AHEALTH BENEFITSPLAN.1. I select 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:)NAME OF PLANOPTION (HIGH OR LOW)2. In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under   age 19, including legally adopted children, and stepchildren and illegitimate children who live with you in a regular parent-child relation-   ship. Include also any unmarried child over 19 who became 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 MEMBERSDATE OF BIRTH(Month, Day, Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)Wife orHusband L Travis 1/1/21[5][6][7][8][9][10]**THIS PART MUST**ALSO BE FILLEDIN IF YOUCHANGE 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.)   YES [ ] NO [ ]**PART C**FILL IN THISPART IF YOUELECT NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.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 enroll-   ment 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. [ ]2. I elect to cancel my present enroll   ment under the Health Benefits Act. [ ]**PART D**FILL IN THISPART IF YOUWISH TOCHANGE YOURENROLLMENTI elect to change my enrollment as shown by the enrollment number and other information in Part A1. Enrollment code number of present plan. 2. Number of event which permits change 3. Date of event which permits change   (See table on back of certificate for proper number)   421 2 AUG 6 1960**PART E**ALL ITEMSSHOULD BECOMPLETEDIN THIS PART.![signature] J. Travis Jr.1. HOME AND ADDRESS OF EMPLOYING OFFICEWARNING—Any intentional false statement inthis application or willful misrepresentation relativethereto is a violation of the law punishable by afine of not more than $10,000 or imprisonment ofnot more than 5 years, or both. (18 U.S.C. 1001.)**PART F**TO BECOMPLETEDBYAGENCY.![signature] J. L. BischoffHEALTH BENEFITS OFFICER2. DATE RECEIVED IN   EMPLOYING OFFICE   8/11/604. PAYROLL OFFICE NO.3. EFFECTIVE DATE OF   ELECTION   1/1/165. PAYROLL ACTION   INITIALS AND DATE)**REMARKS**FOR OPM USE ONLYAGENCY TRANINTSNOTATIONSTriplicate—To Employing Office116032APRIL 1960