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# HEALTH BENEFITS REGISTRATION FORMFEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM(Read instructions on back of page 3.)TO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN.New Carrier's Control No.22933820Old Carrier's Control No.# PART AALL WHO REGISTER MUST FILL IN THIS PART.1. NAME (LAST)   Collin4. YOUR MAILING ADDRESS   1630 Hobart St. NW   (CITY)   WASHINGTON D.C.   (FIRST)   Wendy   (NUMBER AND STREET)   (STATE)   (MIDDLE INITIAL)   S   (ZIP CODE)   200072. DATE OF BIRTH (Use numbers)   MONTH DAY YEAR   03 22 535. SOCIAL SECURITY ACCOUNT NUMBER3. ARE YOU NOW MARRIED?   Yes 1   No 26. SEX   MALE 1   FEMALE 2IMPORTANTIT 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 THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER ENROLLMENT MUST BE CANCELED OR CHANGED TO SELF ONLY. SIMILARLY, IF A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR HER) OWN ENROLLMENT, YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES 2 AND 3.# PART BFILL IN THIS PART IF YOU WISH TO ENROLL OR CHANGE YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN.1. 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 brochure of the plan you select.)NAME OF PLANBlue Cross/Blue Shield Service/Benefit PlanOPTION (HIGH OR LOW)HIGHENROLLMENT CODE NUMBERIf enrollment is for Self Only, answer item 1. If enrollment is for Self and Family, also answer item 2.2. 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 22 who became disabled before age 22 and who, because of the disability, is incapable of self-support. (Attach a doctor's certificate for a disabled child age 22 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.NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)Wife or Husband16273849510IF YOU ARE CHANGING YOUR ENROLLMENT ALSO FILL IN PART D.# PART CFILL IN THIS PART IF YOU WISH NOT TO ENROLL OR IF YOU WISH TO CANCEL YOUR ENROLLMENT.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 PROGRAM.2. I ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THE CODE NUMBER SHOWN BELOW   Present Enrollment Code Number   If you elect to cancel be sure to read "Cancellation of Enrollment" on back of page 3.# PART DFILL IN THIS PART, AS WELL AS PART B. TO. CHANGE YOUR REGISTRATION.ANSWER ITEMS 1, 2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE:1. ENROLLMENT CODE NUMBER OF PRESENT PLAN2. NUMBER OF EVENT WHICH PERMITS CHANGE. (See table on back of page 2 for proper number.)3. DATE OF EVENT WHICH PERMITS CHANGE.   MONTH DAY YEAR# PART EALL WHO REGISTER MUST FILL IN THIS PART.Wendy S. Collin(YOUR SIGNATURE. DO NOT PRINT)Aug 5, 1978(DATE)1. NAME AND ADDRESS (INCLUDING ZIP CODE). OF EMPLOYING OFFICE.   U.S. House of Representatives   Office of Finance, Washington, D.C. 20515WARNING.-Any intentional false statement in this application or wilful 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.)# PART FTO BE COMPLETED BY AGENCY2. DATE RECEIVED IN EMPLOYING OFFICE3. EFFECTIVE DATE OF ELECTION4. PAYROLL OFFICE NO.5. SF 2811 REPORT NO.REMARKSFOR USE ONLY BY AGENCY.(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)NW 88326DocId:32243290' Page 8Page 3 - For Official Personnel FolderStandard Form No. 2809U.S. Civil Service CommissionFPM Supplement 890-1