} 104 Anis “10044 To avoid delay—I. Read information carefully; in full; ypewrite or print in in A. PERSONAL INFORMATION (Last) (First) (Middie} 2. DATE OF BIRTH 3. SOCIAL SECUR' MR (Month) (Dey) — (Year) 3s TARASOFF Boris Dimitri Nov 2 1908 4. ADDRESS {Number ond street) {City and Seate) (Zip Code) : os corres; [Rancho Contento,-S:A., Apartado Postal 2707, Guadalajara, Jal., Mexico | cuecxs, Union Trust Company of the District of Columbia, P.O. » Ben Franklin Stn., Washington, D.C. 20044 i: 0~54 5. (A) ARE YOU 6. (B) IF “YES.” GIVE THE FOLLOWING INFORMATION: MARRIED? WIFE'S OR HUSBAND'S NAME [HER (OR HIS) BIRTH DATE] DATE OF MARRIAGE ADDRESS OF SPOUSE IF DIFFERENT FROM ITEM 4 [x] ve (Firse} (Middie) (Month). (Day) = (Year) (Month) {Day} (Year) Ss 1 wo Anna May 5 23] Mar 10 45 N/A B. CIVILIAN SERVICE 1. OFFICE OF ASSIGNMENT 2. SERVICE DESIGNATION] 3. LOCATION OF EMPLOYMENT (City and State) DDP/WH Mexico City 4 TITLE OF LAST POSITION . : carl S$. DATE: OF FINAL. SEPARATION (Month). (Day) (Year) - -) 6 ARF ROXIMATE NUMBER OF YEARS OF Staff Agent Nov 30 1970 — 15 7. DO YOU HAVE FEDERAL EMPLOYEES GROUP LIFE INSURANCE!- 8. ARE YOU ENROLLED IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM? YES C] NO YES C] NO C. MILITARY SERVICE |. COMPLETE THE SCHEDULE BELOW IF YOU HAVE PERFORMED ACTIVE DUTY THAT TERMINATED UNDER HONORABLE CONDITIONS IN ANY OF THE FOLLOWING SERV. ICES: o ARMY. NAVY, MARINE CORPS, AIR FORCE. OR COAST GUARD OF THE UNITED STATES; OR {) REGULAR CORPS OR RESERVE CORPS OF THE PUBLIC HEALTH SURVEY AFTER JUNE 30, 1961, IF AVAILABLE. ATTACH A COPY OF SERVICE AFTER JUNE 30, 1960: OR (C) AS A COMMISSIONED OFFICER OF THE COAST AND GEODETIC seacn oF sence DISCHARGE CERTIFICATE. DATE OF ENTRANCE | DATE OF ACTIVE DUTY. LAST | UST SPE | ORGANIZATION aT _ DISCHARGE Red(e U.S. ‘Army 20 248 288 3 Feb 1941 20 Oct 45 Tec 4 ” Depot 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 ITARY 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 li, PUBLIC LAW 60-810)? CL] YES id NO ‘i YES NO C] YES NO D. DISABILITY INFORMATION Only applicants for total disability retirement will 1. WHEN DID YOU BECOME TOTALLY DISABLED! — (Month, 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.) RETURN To CIA Background Use Only Do Not Reproduce E. OTHER CLAIM INFORMATION 1. (A) HAVE YOU EVER RECEIVED OR MADE APPLICATION FOR COMPENSATION | |. (B) IF “YES.” STATE THE NUMBER OF YOUR COMPENSATION CLAIM AND THE UNDER THE FEDERAL EMPLOYEES’ COMPENSATION ACT? PERIOD FOR WHICH YOU RECEIVED COMPENSATION f CLAIM NUMBER FROM (Month) (Dey) (Yeor) [TO (Month) (Doy) (Year) XC) ves [no 2. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIVIL SERVICE | 2. (8) iF “YES,” INDICATE THE TYPEG) OF APPLICATION RETIREMENT SYSTEM, INCLUDING APPLICATION FOR RETIREMENT, REFUND, ND GIVE THE CLAIM Nove (S) IF KNOWN CLAIM NUMBER(S) ? DEPOSIT OR REDEPOSIT, OR VOLUNTARY CONTRIBUTIONS! oO RETIREMENT 0 DEPOSIT OR REDEPOSIT VOLUNTARY - CD ves A no {_] rerunp CONTRIBUTIONS 3. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIA RETIRE- | 3. (B) IF “YES.” INDICATE THE TYPE(S) OF APPLICATION: ba MENT & DISABILITY SYSTEM, INCLUDING APPLICATION FOR RETIREMENT, REFUND, PURCHASE OF SERVICE CREDIT, OR VOLUNTARY. ye, - C] RETIREMENT Ci. PURCHASE OF SERVICE CREDIT C YES NO O REFUND CO VOLUNTARY CONTRIBUTIONS 4. (A) HAVE YOU EVER BEEN ere cou SER tener RETIREMENT SYSTEM 4. (B) IF “YES.” GIVE THE NAME OF THE OTHER RETIREMENT SYSTEM (STR La 2 . FOR FEDERAL OR (Kres  (Clno Civil Service System 3 fay
[_ANITIALS | 1. [B.T. ANNUITY WITH SURVIVOR BENEFIT 70 WIDOW OR WIDOWER “Linas | ANNUITY WITHOUT SURVIVOR BENEFIT FOR HER (OR HIS) BENEFIT. survivor annuity benefit after my death.) ANNUITY WITHOUT SURVIVOR BENEFIT 1. if you want all your annuity used as the base for the survivor benefit, write the word “all” in the box below. If you went | -- only part of your annuity used as the base for the survivor benefit, write the yearly ameunt of your ennulty you went used. rs ICATE, BY. SIGNING YOUR INITIALS IN THE APPROPRIATE BOX BELOW, THE TYPE OF ANNUITY YOU WANT TO ‘RECEIVE. READ THE EXPLANATIONS AND ‘LoNSiDER THE MATTER CAREFULLY. NO CHANGE WILL BE PERMITTED AFTER AN ANNUITY HAS BEEN GRANTED. VIVOR BENEFIT, BE SURE TO GIVE THE OTHER INFORMATION CALLED FOR. ° F. TYPES OF ANNUITY: MARRIED APPLICANTS ONLY SPECIFY THE PORTION OF YOUR ANNUITY YOU WANT USED AS THE BASE FOR YOUR WIDOW'S (OR WIDOWER’S) SURVIVOR ANNUITY. THE SURVIVOR'S ANNUITY WiLL BE 55% OF ALL OR WHAT. EVER PORTION OF YOUR ANNUITY YOU SPECIFY AS THE BASE “© If you choose this type, your wife (or busband) cannot be paid 2 (I do not desire my wife (or husband) to receive a G. TYPES OF ANNUITY: UNMARRIED APPLICANTS. ONLY {including ‘Widowed and Divorced) Pinas | ANNUITY WITH SURVIVOR BENEFIT 10 NAMED P 2. | D PERSON HAVING AN INSURABLE INTEREST — SPECIFY THE NAME, RELATIONSHIP AND DATE OF BIRTH OF THE PERSON YOU WISH TQ RECEIVE THE SURVIVOR ANNUITY MAME OF PERSON ( First, middle, last} , DATE OF BIRTH (Mo.. day, yr.) SEE UNMARRIED EMPLOYEES UNDER INFORMATION REGARDING SURVIVOR |. AMNUITIES ON THE ATTACHED INFORMATION SHEET FOR EXPLANA TION IN YOUR ANNUITY. : — — H. CERTIFICATION OF APPLICANT of not more than 5 years, or both (18 U.3.C. 1001). WARNING.—Any intentional false statement im this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment TION OF REDUC- I hereby ce b to the best of my Knowledge and belief. 16 July 1970 iF YOU WANT AN ANNUITY WITH A SUR- ® If you are married. you will receive this type of annuity unless you choose the annuity in F. 2. . ~br@ The annuity payable to you during your lifetime will be reduced by 2147, 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 used. . ® 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 benefit. You cannot use any extra annuity which may be payable to make up the guaranteed minimum annuity. ® 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 begin upon your death and end when she (or he) dies or remarries. ’ a survivor annuity after your death. ® This type provides annuity payments to you only. ® Jf you are not married, you will receive this type of annuity unless you choose the anntity in G. 2. This type provides annuity payments to you only. This type is available to all retiring unmarried employees who are in good health. . It provides a reduced annuity to you and a survivor amuity to the person named as having an insurable interest. . The survivor's annuity will begin upon your death and end when she (or he) dies. The survivor’s annuity will be 557, of the reduced annuity you If you choose this type, you will have to undergo a medical examination which will be arranged by the Director of Personnel at no cost to you. ‘If the person-named as having an insurable interest should die before you, no chahge in type of annuity will be permitted, your annuity will not be increased, nor may you name any other person as survivor.. certify that all statements made in this application are true /s/ Boris D. Tarasoff (DATE) “(SIGNATURE OF APPLICANT)