“ELECTION, DECLINATION, OR WAIVER i IMPORTANT OF LIFE INSURANCE COVERAGE | AGENCY INSTRUCTIONS FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM ON BACK OF ORIGINAL TO COMPLETE THIS FORMo ] FOLLOW THESE GENERAL INSTRUCTIONS: “s * Reud the back of the “Duplicate” carefully before you fill in the form. ® @ilin BOTH COPIES of the form, Type or use ink. ® Ce not detach any part. 2 FILL IN Trg IDENTIFYING INFORMATION BELOW (please print of type}: rae i tins) migaiey "_ OATE OF BIRTH (month, day. year)” | SOCIAL Stcudity NUMBER t i i - . 1 i SENADUW JER MY K. | | “i OVS OEPARTMERT OF AGENCY : | LOCATION (City, State, 21° Code} ; | 3 MARK AN “X" IN ONE OF THE BOXES BELOW (do NOT mark more then one}; Mark Aer ELECTION OF OPTIONAL ON ADDITION To REGULAR) INBURANCE if you ae i etect the $10.000 addtional optional insurance and authorize the required daductions WANT BOTH x from my salary, compensation, or annuity to pay the full cost of the optional insurance. optional sca . ‘frms options! INSUFANCO 141M addition to my fegular insurance. regular : instrance (A) DECLINATION OF OPTIONAL (BUT NOT REGULAR) INSURANCE Mark here if you I dachne ihe $10,000 additianal optional insurance. 1 understand that § cannot elect op- DO NOT WANT Honai insurance unti at least 1 year after the eRectree date cf tes declination and untess OPTIONAL fut | atthe me f apply tor att an under age 50 and present satisfactory medical evidence a sant Of ngerability. 2 understand aiso that my tegular ingurance 1s not affected Dy this declina- £0 w (B) tos of aguinonel 6phenat insurance. regular insurance 1 Marth here WAIVER OF LIFE INSURANCE COVERAGE if you J dese rot to be insured and i waive Coverage under ths Federal Omniavees Group Lite WANT NEITHER i inqurance Program, } SNGerstand that § cannce Cancel tha waver and ottain enular in. regular nee | Sulerca untd at joast t yeeor efter ttia etfecine Gate of thes waver art vtiess ating ting . ° Serene §apory for insurance tam under sce 0 andpresent balsfactory medical es dence cian. optional (¢) Suratedy, § enderstand also that t Cannot how oF falar have the $10.0) sdditional  itsurance Optra Miwsance untssg | Rave {he soguler Maur ane mere tem m2 S82 Neem tee eee So nr renee SIGN AND GATE tf YOU MARKED BOX “At OR HEH FOR EMPLOYING OFFICE USE ONLY COMPLETE Teel “STATISTICAL STUB” THEN RETURN . ofa ’ Pe at ry | THE ENTIRE FORM TO YOUR EMPOVING OFFICE | teatat rovaiseg gate tee) | yr sy _—e nl 7 2 . i Pa oar | se now Vetes of UBne ae betes ms bend Hae eae f= ete igen ena Stoner tet ote AN MS cee cm se eee fee ta maecs Ent amend, Case str ci me | gag? a Ce ee 2 peer narra cRaamaeereter, | ach PO a I on | mic ate COPt Agen es itee DUALICATE CO memes Te um ea es ten th Ube. . 17s 2e > oat a ome
UAE PROCESSING ACON ECRET | . few foe NoNtING Ch ] et » WH Division ! XN fre imorsines erquieto BS Sree aererrenrn rene ae } ewe OUAIID Ot5m . ie jas WDSt Pein ainG an rior of Staton main apne? aa - on haldialieemmees _Chict of Station, nex tee, Lity < ” re ec Abt SISTI RATI VEY BE RSONS “ Vansindt tal of _Forms aE T=. ACTON Et RiQUIPID. em tein i ACTION REQUIRED: Process Forms Tees a ter in a te nant tne eee at TITS errr ntti nts ene REFERENCE: FN 20-86, dated 2 February 1968 Forwarded herowith are the forms for the below listed porsonnel: oe f Jeremy kK. BENADUM eer - Wlllard Cc. CURTIS ATTACHMENTS: Forms SF 176-T (HEREWITH) DISTRLBUTION: _ d= Chief, Wi Division w/atts (5) cat anaml is errs eT osseatin ined IAD mans — i ry rns i t | HMMT<ATA? i 20 February 190N eee renee memes aa remnant: aensan: fete enn “eueaaticy TE a cea aguas pT entree ae S ECRE 7 - rane sete ee EBT SEED, NP Pana STS Nad Rae tht cert Maat PE ye
awi Information Cnly. i a ateee og : + a | TERENCE DOORMAN -5749, dated 11 eankary Loos, tleation Resores have Been forwarded for the ! as Loilows: DATE i i co tha cont t i Resorts for a: otomber of cuch yeEPUESd Tor : fp Of gach year. i ; 1 j ? ' Pe . ae fed Boe Bey 1 . s i i < . SS TTR mone ae tee Rn eee ee, wt ed eat at as wv Pale Lt bbl ale, gd hd Se seen
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, DISPATCH [+ Menem see cee nee nant om Jen WH Divisston — ; ; al aan 7 i ytae de hE TADEAS | ‘chigt of Station, Mexico City {> . i Uh, 7” ~~ ~ ne - ee Adain/ Personnel, ~ Current Residence aad Duepuendeney Repo ts FAHON KIQUELD beitadters . ee ~ee i a ; } ACTION REQUIRED:  Tnformation Only , ; . Foxwarded under separate cover ara tho current vesddcnee and and Me | dependency reports Lor Jovemy kK. RENADUM, | eee ee 7 TAL BAND C.? CURTIS ° Attachments: As Stated Above, use Distribution: joo 7 Chiel, WH Division, w/att ORS BE TG SBS Any RULE es ra |. Hsiat -~ KSSL “io Decembar 1067 Ra Phe ode . ot . . . wet st pte ” ee he ee i ee a a bee Bayle af UA ASH SEC hE T
Wee mee ae ee oe ' , ) COUTOENTIAL eee Batted dary ve cay » Phe data secudedon this lumis essential in determinin COLEn fedurre et a at Oo ate ne te nee hg an TRANG Oe Bogen esee t lant ae aus eI Sit | “RE iuince LATA 1 rege By MeFTIA LE " PearLre, WY AGEME®? i LAGE Plas Léxtao, D, F. L AGE tes Cet teat “TAL Us, “he Sin ATE fe As be aan & ChE ep Feareiseo, Colifornta MARITAL STATUS f0; srag ATE C lovonenn 9341.0 { [warms . te VANINIAGE ‘rutelaco, California Ve oronce ‘ts, ‘pLas ao oor OV6ner “‘Urcure ‘7 Errireers ‘br "FL ‘ace! S6eas <p BE Baal P For Teta cy riers », INDICATE MAtMEIBY OF BPO tr Paha Tita ~ emcee ee AY WO de A 54a a H £4, ADU . an) Ww ” v | n 8 #9 u “ Wooo i) —__ (Cont, ) NAME GF Gun 9a TH at tale suanitan) Anne __] I_{Decenasadg. a Pe & bry z a Fatt te Cte fesnatea whe meas iA ot ay Santa Earbara, | wT ase osey COND ES 188 BO6 bee ee ey, NEO TCAs CASE GF Qteverd o APOUany OF Gaecininent me; HN Gtersegs duty, fefuen to teaidence Upon Separation, and bor prosiching eusen a thee vent ofon employer eitregency, The oriqinal ofthis For will | he filed inthe ein rae te nase ne & noni Le a or er MPF RCE San rane teen, Cul irornia ana MEMBERS OF AMILY - we ee BOP BE eC neta ete ean . a nmenenwer HAMP GF SH GUsE | [ ALOR DS Ie. + Strwet, City, | tone, 5 Stata) Ce 2 Lo. O50 de Agua 43," u oe ree. 11320 M4gnton Ridges zd, Peete FATAL Y VP ave, nas foil (GLO oF ¥OuIe AFF iia tics ‘@ifar Dae ROEHC meno Cag Fronoisao, ¢ AUD Ta reisy nfres, phryon alineuule an idene oo cones os PAL | fora, ARE OR eee. eememetomteae a gece, 7 Calir, ae gy ILA oe WFO uO eae POBMEG ABOTE wir: , tion he Lalievag vtAs eer far.) G OF 16um was S BEL | Veg ET TI et ee ee ec % Poets OO SLU AL OT MORIZED 70 Mane GECIS ate Hane atid DihilEE ag of peraun, tf oy, whe tan make cur A 4tatefona ae case ef finergatcy.) COMTI ey Cote REV ESS: site Business OUR SS tiho., Street, Cry, Zone, States arty Pam eae tpg CMPLOVE R, er APP UiCaAaLE CF APRIIATION? 7 fi, Cera? dive rane end ahieae £ we OY Ve Aue The poreuns famed in stem 3 store n may alee be fot.beod in cane of Omergency, IF SUCH NS biftc ATIC CAUSE ‘= OF HEALTH OR OTHER REASONS, PLEASE 19 STATE In ITE é ON THE RE VERSE SOE GF Tisis ee ee ‘of G6 Ghee, AMIS a Silene iw «thse, val ; suncection with leave Le isd dependency infor. “Oe “te eT apyas sonnel folder l1lfornta ra Gel ane i 1 ‘ at EE NI Le BN IG Be: PCAPAL LE 9 fGb ree ~ i AMPUL LZo eT te an ree ean on TACT t% fans A ene nett ce oF MARRIAQE TI=hs OF Gere Loa a 6U6 bos).
14-00000 VNTASY LNT are ye Liege ‘ lon mey prowe very usetel to vou f aS Sea wotrant, . a eee peg ALTO GN ET AAS SP ONEING NEED A DLO Bit oe BOC VSL Saas ACCOUNT Ref Tied aman SN erence pee ae. PR SANT OU ater oe, } ‘ Lf, wat en t Se e° 2 Byer Cate Wells Fergoe Senk, ify Califernia Street, Sen Fronolacs, Coli, MEE VON AME MILK OF Pet TOT) oR carat wmleuP (J res TD xe Te YES, DO VOU HAVE A JOINT ACCOUNT? { }res Two tener cert Stet ener ZOU COMPLETED A LAST WILT ANG TEYTAMUNT® [gl Yes (] No. uF tY ea” eneee ts ducument tucated?) Oe gOS 8 8 atetene 9 Cee see eRe meme ewe: a ea tet ee ree es. nate neta ate - eer PLA? AN ARTPANGIDD SVAN DIAN Sm OP YOUN CMILOMEN IN CASS OF COMMON DISASPER TO GOTH PARE MTS?” “} 4G. C2 FY oun? give nase’ a’ aot entrant! | — soa ape oe eee reer aren and ius. rn —— RAVE YOU CKECUTED A POWER OF ATT ORNE ?? Hi 7} WES xo NOL (LP? Fee”, ee feaersa the power'of elfomey 2) = " ADDITIONAL CATA ANI ONTINUATION OF PRECEDING ITEMS _ ae Selita intent see ETON | TT awe Sexe 3. (Cont.) Children: Address (Sere as Iindfested fr others) on 7 te a et unity. of Santa Clara, Sa Clara, calit, (during s ' eee oe, anes ee eemanre ccm st eaten er Stamey aetna Geant Gr aay Sterns eet ue al eee cen enact me gtrinenaloe higsa D At Oates, pVGreatyre - /, . : iad < : . oe wey. uixteo, DF. 11S Pee., 1967 FE. LAA f { 3 * tg ot
oECR UT ‘s Chiet of Stathun, Mexico City X } i . car \ DENADL, Jeresy Ke Action Requireu: As notes : \ ‘The attached Fora G1 should be cospleted in duplicate ax] | by BLSAAM, | ans forwarded to igs. It is inportant that the inforaaticn contained on the foru be filed in ligs, therefere, vapid respense would be appreciated, .- i AkCaciaent ¢ AS stated (h/y) Distributicus Z2 » GS, Hexico City BMS © 5668 SECRLT Distribution: mi/contracts, | isr (14 Nav 67) 444g 1 = RIU/Rep 1 > hi/Contracts CHUL