APPLICATION FOR RETIREMENT.
Originator: CIA
From: BORIS D. TARASOFF
To: CIA RETIREMENT BOARD
Document date: 07/16/1970
Document type: PAPER - TEXTUAL DOCUMENT

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104-10131-10041

2023 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992

Al

LICATIQN FOR RETIREME!

To avoid delay—. Read information carefully:

NAME

MR

(Last)

TARASOFE

(First)

Вогів

2. Complete application in full;

A. PERSONAL INFORMATION

(Middle)

2. DATE OF BIRTH

(Manch)

(Day)

Dimitri

Nov

3. Typewrite or print in ink

(Year)

1908

4. ADDRESS

(Number and street)

(City and State)

3. SOCIAL SECURE NUMBER

{079 05 96247

(Zip Code)

Rancho Contento, S. A., Apartado Postal 2707, Guadalajara, Jal., Mexico]

CHECKS:

Union Trust Company of the District of Columbia,

P. 0.

Box 481, Ben

Franklin Stn., Washington, D.C.

20044

5. (A) ARE YOU

6. (B) IF "YES." GIVE THE FOLLOWING INFORMATION:

(Acct, #7-110-545)]

MARRIED!

WIFE'S OR HUSBAND'S NAME

(First)

(Middle)

(Month).

Year

DATE OF MARRIAGI

Month) (Day) (Year

ADDRESS OF SPOUSE IF DIFFERENT FROM ITEM 4

YES

NO

Anna

1. OFFICE OF ASSIGNMENT

May

5

23

Mar 10 45

N/A

B. CIVILIAN SERVICE

2. SERVICE DESIGNATION, 3. LOCATION OF EMPLOYMENT (City and Stote)

DDP/WH

4 TITLE OF LAST POSITION

Staff Agent

7. DO YOU HAVE FEDERAL EMPLOYEES GROUP LIFE INSURANCE! -

IX YES

D

Mexico City

5. DATE: OF FINAL. SEPARATION (Monch)... (Day) (Year)

1 6. APPROXIMATE NUMBER OF YEARS OF

Nov 30 1970

CIVILIAN SERVICE

15

8. ARE YOU ENROLLED IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS

PROGRAM?

1X YES

J NO

• 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:

(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

SERVICE AFTER JUNE 30.

1960: OR (C) AS A COMMISSIONED OFFICER OF THE COAST AND GEODETIC SURVEY AFTER JUNE 30. 1961.

IF AVAILABLE. ATTACH A COPY OF

YOUR DISCHARGE CERTIFICATE.

BRANCH OF SERVICE

SERIAL NUMBER

DATE OF ENTRANCE

ON ACTIVE DUTY

ATE OF SEPARATION

ROM ACTIVE DUT

LAS GRADE

U.S. Army

20 248 288

3 Feb 1941

20 Oct 45

Tec 4

ORGANIZATION AT DISCHARGE

Div., Regr., Co., etc.

loth Reinforcement

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.

UNDER CHAPTER 67, TITLE 10. U.S.C.

INACTIVE)?

COMPENSATION.)

TITLE III, PUBLIC LAW 80 810)?

YES

NO

_YES

XI NO

• YES

& NO

D. DISABILITY INFORMATION

Only applicants for total disability retirement will

i. WHEN DID YOU BECOME TOTALLY DISABLED! (Manen, year)

complete Part D.

2. BOOTTONES COM YOUT ON PLATE SHEET OF WHEN INCUSS AND HOW THEY INTERFERE WITH PERFORMANCE OF THE DUTTES OF YOUR POSITION. CATTACH

RETURN TO CIA

Background Use Only

Do Not Reproduce

E. OTHER CLAIM INFORMATION

I. (A) HAVE YOU EVER RECEIVED

OR MADE APPLICATION FOR COMPENSATION

UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT!

1 ® FEMO A WHICH NO RECENCO CON CONRENGATON CLAM AND THE

CLAIM NUMBER

FROM (Moneh) (Doy) (Year)

TO (Month) (Day) (Year)

• YES

& NO

• (A) HEYE ON SIS. INCLUDING APPLICATION FOR RETIREMENT. REFUNI

RETIREMENT SYSTEM.

ICLUDING APPLICATION FO

DEPOSIT OR REDEPOSIT, OR VOLUNTARY CONTRIBUTIONS!

YES

I NO

3. (A) MANT YOU SABIOUS SYSTEM. INCLUDING APPLICATION FOR RETIREMENT

1ENT & DISABILITY

INCLUDING

REFUND. PURCHASE OF SERVICE CREDIT, OR VOLUNTARY .CONTRIBUTIONS?

NO

1. A) LON FOR A OR BENET ON COUMAN EMPOPES TREE SISTE

" No

2(8) NO GIVE HE CHATH NURE SI APRONTON

_ RETIREMENT

• DEPOSIT OR REDEPOSIT

_REFUND

I VOLUATUTIONS

3. (B) IF "YES:" INDICATE THE TYPE(S) OF APPLICATION:

RETIREMENT

. PURCHASE OF SERVICE CREDIT

REFUND

_ VOLUNTARY CONTRIBUTIONS

4. (B) IF "YES," GIVE THE NAME OF THE OTHER RETIREMENT SYSTEM

CiviL Service System

CLAIM NUMBER(S)

3/AU

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2.

1

2

EDICATE, BY. SIGNING YOUR INITIALS IN THE APPROPRIATE BOX BELOW, THE TYPE OF ANNUTTY YOU WANT TO RECEIVE.

READ THE EXPLANATIONS AND

LONSIDER 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 CALLES FOR.

F. TYPES OF ANNUITY: MARRIED APPLICANTS ONLY

INITIALS

в. Т.

ANNUITY WITH SURVIVOR BENEFIT TO

WIDOW OR WIDOWER

• If you are married, you will receive this type of annuity unless

you choose the annuity in F. 2.

• The annuity payable to you during your lifetime will be reduced

by 2½% of any amount up to $3,600 a year used as the base for

SPECIFY THE PORTION OF YOUR ANNUITY YOU WANT USED AS THE BASE

FOR YOUR WIDOW'S (OR WIDOWER'S) SURVIVOR ANNUITY:

the survivor benefit, plus 10% of any amount over $3,600 so

used.

• If you retire for total disability before age 60 and get a guar-

It you want all your annuity used as the base for the survivor

bonofit, write the word. "all' in the bax below.

If you word.

only part of your ornuity used as the base for the survivor

benafit, write the yearly amount of your annulry you wort used.

anteed minimum disability annuity, you may use all or any par

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-

SALL

THE SURVIVOR'S ANNUITY WILL BE 55% OF ALL OR WHAT

VER PORTION OF YOUR ANNUITY YOU SPECIFY AS THE BASE

FOR HER (OR HIS) BENEFIT.

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.

INITIALS

ANNUITY WITHOUT SURVIVOR BENEFIT

*• If you choose this type, your wife (or husband) cannot be paid

a survivor annuity after your death

(1 do not desire my wife (or husband) to receive a

survivor annuity beneft after my death.)

• This type provides annuity payments to you only.

G.

TYPES OF ANNUITY: UNMARRIED APPLICANTS. ONLY (Including Widowed and Divorced)

INITIALS

ANNUITY WITHOUT SURVIVOR BENEFIT

• If you are not married, you

will receive this type of annuity

unless you choose the annüity in G. 2.

• This type provides annuity payments to you only.

INITIALS

ANNUITY WITH SURVIVOR BENEFIT TO

NAMED PERSON HAVING AN INSURABLE

INTEREST

SPECIFY THE NAME, RELATIONSHIP AND DATE OF BIRTH OF THE PERSON YOU WISH

TO RECEIVE THE SURVIVOR ANNUITY

NAME OF PERSON (Firse, middle, last)

RELATIONSHIP

DATE OF BIRTH (Mo.. day, yr.)

SEE UNMARRIED EMPLOYEES UNDER INFORMATION REGARDING SURVIVOR

ANNUITIES ON THE ATTACHED INFORMJATION SHEET FOR EXPLANATION OF REDÚC.

TION IN YOUR ANNUITY.

• This type is available to all retiring unmarried employees who ar

good healtl

• It provides a reduced annuity to you and a survivor annuity to

the person hamed as having an insurable interest.

• The survivor's annuity will begin upon your death and end when

she (or he) dies.

fee survivor's annuity will be 55% 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 change in type of annuity will be permitted, your

annuity will not be increased, nor may you name any other

person as survivor.

H. CERTIFICATION OF APPLICANT

to the rest of may how al e a Sets made in this application are true

WARNING.-Any intentional false statement in 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

of not more than S years, or both (18 U.S.C. 1001).

16 July 1970

(DATE)

/s/ Boris D. Tarasoff

(SIGNATURE OF APPLICANT)

FOR OFFICE OF PERSONNEL USE ONLY

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