[tostoistA0oog} | - . \ To avoid delay—-|. Read information carefully; 2. Complete application in full; . Typewrite or print in in A. PERSONAL INFORMATION f. NAME {Lest} {First} {Middle} 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER MR . {Month} (Dey) {Yeor) R wie? SWENSON Harold Francis April 28, 1915 144-07-7204 4. ADDRESS {Nurnber ond street) (City ond State} (Zip Code} CORRES: 5005 “dgemoor Lane, Bethesda, Maryland . 20014 CHECKS: American Securi 5. (A) ARE YOU MARRIED? YES [} no Mildred Chandler WIFE'S OR HUSBAND’S NAME |HER (OR HIS) BIRTH DATE] DATE OF MARRIAGE Fi {First} (Middie) (Month) Day} (Year) (Month) (Day) (Yeer) {, OFFICE OF ASSIGNMENT DDP/EUR D 4. TITLE OF LAST POSITION . 5. DATE OF FINAL SEPARATION (Month) (Dey) (Year) 6, APPROXIMATE NUMBER OF YEARS OF oO . } f y 3 1 1968 CIVILIAN SERVICE 20 7. DO YOU HAVE FEDERAL EMPLOYEES GROUP LIFE INSURANCE? 8. Oe aaa ENROLLED IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS [Mves [Ino (ves [Ino C. MILITARY SERVICE 1. COMPLETE THE SCHEDULE BELOW IF YOU HAVE PERFORMED ACTIVE DUTY THAT TERMINATED UNDER HONORABLE CONDITIONS IN ANY OF THE FOLLOWING SERV- ICES: (A) ARMY, NAVY. MARINE CORPS, AIR FORCE OR COAST GUARD OF THE UNITED STATES: OR (B) REGULAR CORPS OR RESERVE CORPS OF THE PUBLIC HEALTH SERVI E AFTER JUNE 30, 1960; OR (C) ASA COMMISSIONED OFFICER OF THE COAST AND GEODETIC SURVEY AFTER JUNE 30, 1961. IF AVAILABLE. ATTACH A COPY OF YOUR . : DATE OF ENTRANCE | DATE OF SEPARATION LAST GRADE ORGANIZATION AT DISCHARGE J.5. Marine ¢ March anuary Marine Torpedo Corps 035838 1946 ng Squad 2. (A) ARE YOU A MILITARY RE-| 2. (B) ARE YOU IN RECEIPT OF OR HAVE YOU EVER APPLIED FOR | 2. (C) IF “YES,” WERE YOU RETIRED FROM A RESERVE COMPO. SERVIST (EITHER ACTIVE MILITARY RETIRED PAY? (RETIRED PAY DOES NOT IN- NENT UNDER CHAPTER 67, TITLE 10, U.S.C. (FORMERLY OR INACTIVE? . CLUDE V.A. PENSION OR COMPENSATION) = TITLE ft, PUBLIC LAW 80-810)? Retired | | ves Ll no ° (] ves KK) NO Clves CJ no D. DISABILITY INFORMATION Only applicants for total disability retirement will I, WHEN DID YOU BECOME TOTALLY DISABLED? (Manth. year) - complete Part D. 2. BRIEFLY DESCRIBE YOUR DISABILITIES. STATE WHEN INCURRED, AND HOW THEY INTERFERE WITH PERFORMANCE OF THE DUTIES OF YOUR POSITION. (ATTACH ADDITIONAL COMMENTS ON PLAIN SHEET OF PAPER IF NECESSARY.) . . E. OTHER CLAIM INFORMATION 1. (B) IF “YES.” STATE THE NUMBER OF YOUR COMPENSATION CLAIM AND THE PERIOD FOR WHICH YOU RECEIVED COMPENSATION CLAIM NUMBER - FROM (Month) {Day) (Year) {TO (Month) (Dey) (Year) 2. (B) He “YES.” INDICATE THE TYPE(S) OF APPLICATION ND GIVE THE CLAIM NUMBER(S) IF KNOWN CLAIM NUMBERS) [ay RETIREMENT © [TAL DEPOSIT OR REDEPOSIT , VOLUNTARY (_] reruno CONTRIBUTIONS 3. (B).IF “YES,” INDICATE THE TYPE(S) OF APPLICATION: n [-] RETIREMENT [_] PURCHASE OF SERVICE CREDIT REFUND C) VOLUNTARY CONTRIBUTIONS 4. (B) iF “YES,” GIVE THE NAME OF THE OTHER RETIREMENT SYSTEM Civil Service ‘System. 1. (A) HAVE YOU EVER RECEIVED OR MADE APPLICATION FOR COMPENSATION UNDER THE FEDERAL EMPLOYEES’ COMPENSATION ACT? Ove Eno 2. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIVIL SERVICE RETIREMENT SYSTEM, INCLUDING APPLICATION FOR RETIREMENT, REFUND, OEPOSIT OR REDEPOSIT, OR VOLUNTARY CONTRIBUTIONS? er ¥) ves 3. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIA RETIRE- MENT & DISABILITY SYSTEM, INCLUDING APPLICATION FOR RETIREMENT, REFUND, PURCHASE OF SERVICE CREDIT. OR VOLUNTARY CONTRIBUTIONS? YES NO 4. (A) HAVE YOU EVER BEEN EMPLOYED UNDER ANOTHER RETIREMENT SYSTEM FOR FEDERAL OR DISTRICT OF COUMBIA EMPLOYEES!) ia YES NO- i
wt . a 7 @ ® S ~ ; INDICATE, BY. SIGNING ‘YOUR INITIALS IN THE APPROPRIATE BOX BELOW, THE TYPE OF ANNUITY YOU WANT TO RECEIVE. READ THE EXPLANATIONS AND a fONSIDER THE MATTER CAREFULLY. NO CHANGE WILL BE PERMITTED AFTER AN ANNUITY HAS BEEN GRANTED. If YOU WANT AN ANNUITY WITH A SUR- VIVOR BENEFIT, BE SURE TO GIVE THE OTHER INFORMATION CALLED FOR. - . F. TYPES OF ANNUITY: MARRIED APPLICANTS ONLY ; P| ANNUITY WITH SURVIVOR BENEFIT TO ® you are marred, you will receive this type of annuity unless ~>-@ The annuity payable to you during your lifetime will be reduced by 214%, of any amount up to $3,600 a year used as the base for the survivor benefit, plus 10% of any amount over $3,600 so used. . SPECIFY THE PORTION OF YOUR ANNUITY YOU WANT USED AS THE BASE FOR YOUR WIDOW'S (OR WIDOWER’S) SURVIVOR ANNUITY. If you retire for total disability before age 60 and get a guar- anteed minimum disability annuity, you may use all or any part of your “earned” annuity as the base for the survivor beneft. You cannot use any extra annuity which may be payable to make up the guaranteed minimum annuity. i you want all your annuity used as the base for the surviver benefit, write the word ‘all in the box below. bf you want anly pert of your annuity used as the base for the survivor benefit, write the yearly amount of your annuity you want used. ® if your wife (or husband) should die before you, no change in type of annuity will be permitted, your annuity will not be in- creased, nor may you name any other person as survivor. THE SURVIVOR'S ANNUITY WILL 8E 55% OF ALL OR WHAT- EVER PORTION OF YOUR ANNUITY YOU SPECIFY AS THE BASE FOR HER (OR HIS} BENEFIT. ® The survivor's annuity will begin upon your death and end when she (or he) dies or remarries. : ANNUITY WITHOUT SURVIVOR BENEFIT “> ® If you choose this type. your wife (or husband) cannot be paid a survivor annuity after your death. 2 ( do not desire my wife (or husband) to receive a . . . -{HES 4 survivor annuity benefit after my death.) ® This type provides annuity payments to you only. G. TYPES OF ANNUITY: UNMARRIED APPLICANTS ONLY «(Including Widowed and Divorced) ANNUITY WITHOUT SURVIVOR BENEFIT ® if you are not married, you will receive this type of annuity unless you choose the annuity in G. 2. 1. | | @ This type provides annuity payments to you only. ANNUITY WITH SURVIVOR BENEFIT TO @ This type is available to all retiring unmarried employees who are 2 P| NAMED PERSON HAVING AN INSURABLE tt good health. INTEREST elt provides a reduced annuity to you and a survivor annuity to the person named as having an insurable interest. SPECIFY THE NAME, RELATIONSHIP AND DATE OF BIRTH OF THE PERSON YOU WISH The survivor's annuity will begin upon your death and end when TO RECEIVE THE SURVIVOR ANNUITY . she (or he) dies. NAME OF PERSON (First middle, fast) The survivor's annuity will be 557%, of the reduced annuity you receive. If you choose this type, you will have to undergo a medical RELATIONSHIP ~ | DATE OF BIRTH (Mo. day. yr.) examination which will be arranged by the Director of Personnel at no cost to you. —-@-f the person named as having-an-insurable interest should die - SEE UNMARRIED EMPLOYEES UNDER INFORMATION REGARDING SURVIVOR before you, no.change in-type of annuity will be permitted, her ANNUITIES ON THE ATTACHED INFORMATION SHEET FOR EXPLANATION OF REDUC. annuity will not be increased, nor may you name any other TION IN YOUR ANNUITY. person as survivor. H. CERTIFICATION OF APPLICANT I hereby certify that all statements made in this application are true WARNING.—Any intentional false statement in this application to the best of my knowledge and belief. or willful 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). November 67 CY Harold F. Swengon (DATE) (SIGNATURE OF APPLICANT) ft. FOR OFFICE OF PERSONNEL USE ONLY