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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 CANCELENROLLMENT 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 REGIS-TER MUST FILLIN THIS PART.1. NAME   (LAST)   Collins4. YOUR MAILING ADDRESS   (NUMBER AND STREET)   1630 Hobart St., N.W.(CITY)WASHINgton D.C.(FIRST)Wen Diy(MIDDLE INITIAL)S(STATE)(ZIP CODE)200092. DATE OF BIRTH   (Use numbers)MONTH DAY YEAR03 22 535. SOCIAL SECURITY   ACCOUNT NUMBER   024-44-51683. ARE YOU NOW   MARRIED?   Yes   No6. SEX   MALE   FEMALEIMPORTANTIT IS ILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF YOU ARE ALREADY COVERED THROUGHTHE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHERENROLLMENT 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) OWNENROLLMENT, 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 THISPART IF YOUWISH TO ENROLLOR CHANGEYOUR ENROLL-MENT IN AHEALTH. BENE-FITS PLAN.If enrollment isfor Self Only,answer item 1.If enrollment.is.for Self andFamily, also answer item 2.IF YOU ARECHANGING YOURENROLLMENTALSO FILL INPART D.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 ServiceBenefit PIANOPTION (HIGH OR LOW)HIGHENROLLMENT CODE NUMBER.11012. 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 MEMBERS | DATE OF BIRTH' (Month, Day, Year) || ----------------------- | --------------------------------- || Wife or Husband         | 1                                 ||                         | 2                                 ||                         | 3                                 ||                         | 4                                 ||                         | 5                                 ||                         | 6                                 ||                         | 7                                 ||                         | 8                                 ||                         | 9                                 ||                         | 10                                |PART.CFILL IN THISPART IF YOUWISH NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.PLACE AN "X" IN ITEM 1 OR 2 WHICHEVER APPLIES:1. I ELECT NOT TO ENROLLIN A PLAN UNDER THE FEDERAL   EMPLOYEES HEALTH BENEFITS PROGRAM:2. I ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THE   CODE NUMBER SHOWN BELOWPresent Enrollment Code Number.If you elect to cancelbe sure to read"Cancellation of Enroll-ment" on back of page 3.PART DFILL IN THISPART, AS WELLAS PART B, ΤΟCHANGE YOURREGISTRATION.ANSWER.ITEMS 1,2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE.1. ENROLLMENT CODE NUMBER   OF PRESENT-PLAN-2. 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 YEARPART EALL WHO REGIS-TER MUST FILLIN THIS PART...Wen Dy. S collins(YOUR SIGNATURE DO NOT PRINT)Aug 5, 1978(DATE)WARNING.-Any intentional false statementin this application or wilful misrepresentationrelative thereto is a violation of the lawpunishable by a fine of not more than $10,000or imprisonment of not more than 5 years,or both. (18 U.S.C. 1001.)PART FTO BECOMPLETEDBY AGENCY1. NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICE   U.S. House of Representatives   Office of Finance, Washington, D.C. 205152. DATE RECEIVED IN   EMPLOYING OFFICE3. EFFECTIVE DATE OF   ELECTION4. PAYROLL OFFICE NO.   000048325. SF 2811 REPORT NO.REMARKSFOR USE ONLYBY AGENCY.(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)Page 1 - To Payroll OfficeNW 88326-DocId:32243290 Page 6Standard Form No. 2809U.S. Civil Service Commission,FPM Supplement 890-1November 1972