## Page 1

. .

Assassination Records Review Board

Final Determination Notification

AGENCY

HSCA

RECORD NUMBER: 180-10068-10324

RECORD SERIES

: STAFF PAYROLL RECORDS

AGENCY FILE NUMBER

December 8, 1995

Status of Document:

Postponed in Part

Number of releases of previously postponed information: 8

Reason for Board Action: The Review Board's decision was premised on several factors

including: (a) the significant historical interest in the document in question; (b) the

absence of evidence that the release of the information would cause harm to the United

States or to any individual.

Number of Postponements: 4

Postponements: All the postponements in this document represent Social Security numbers.

Reason for Board Action: The text is redacted because the public disclosure of the redaction could

reasonably be expected to constitute an unwarranted invasion of personal privacy, and that invasion of

privacy would be so substantial that it outweighs the public interest.

Substitute Language: SSN

Date of Next Review: 2017

Board Review Completed: 10/24/95

Heleased under the John F. Kennedy Assassination Records Collection Act of 1992)

144 USC: 2107 Notel. Case#: NW 89326 Date: 2025

NW 88326

Docld:32243290 Page 1

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## Page 2

• ca

JFK ASSASSINATION SYSTEM

IDENTIFICATION FORM

AGENCY INFORMATION

Date: 08/20/93

Page: 1

AGENCY : HSCA

RECORD NUMBER

• 180-10068-10324

RECORDS SERIES :

STAFF PAYROLL RECORDS

AGENCY FILE NUMBER :

DOCUMENT INFORMATION

ORIGINATOR : HSCA

FROM

TO

TITLE :

DATE : 12/29/77

PAGES : 8

SUBJECTS :

HSCA, ADMINISTRATION

COLLINS, WENDY S.

DOCUMENT TYPE : PRINTED FORM

CLASSIFICATION

:

U

RESTRICTIONS

:

3

CURRENT STATUS

P

DATE OF LAST REVIEW: 07/07/93

OPENING CRITERIA :

COMMENTS :

BoX #:1.

[R] - ITEM IS RESTRICTED

NW 88326

Docld:32243290 Page 2

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## Page 3

LOUIS STOKES, OHIO, CHAIRMAN

RICHARDSON PREYER, N.C.

SAMUEL L. DEVINE, OHIO

MANALTER E. PAUNTROT, OU

STEWART B. MCKINNEY, CONN.

"YVONNE BRATHWAITE BURKE, CALIF.

CHARLES THONE, NESR.

CHRISTOPHER J. DODD, CONN.

HAROLD S. SAWYER, MICH.

HAROLD E. FORD, TENN.

FLOYD J. FITHIAN, IND.

ROBERT W. EDGAR, PA.

(202) 225-4624

Select Committee on Assassinations

U.S. House of Representatibes

3369 HOUSE OFFICE BUILDING, ANNEX 2

WASHINGTON, D.C. 20515

December 5, 1978

The Honorable Frank Thompson, Jr.

Chairman

Committee on House Administration

U. S. House of Representatives

Washington, D. C.

20515

Dear Mr. Chairman:

Effective December 1, 1978, the official duty station of Ms. Wendy

Collins has been changed from Washington, D. C. to Pittsford, Vermont.

This change will remain in effect through the balance of the 95th Congress.

LOUIS STOKES

Chairman

LS: th

NW 88326

Docld:32243290 Page 3

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## Page 4

PAYROLL AUTHORIZATION FOOM

(Please Use Typewriter

or Ballpoint Pen)

U.S. HOUSE OF REPRESENTATIVES.

Washington, D:C. 20515

(any erasures, corrections, or changes

on this form must be initialed by the

authorizing official.)

To the Clerk of the House of Representatives:

I hereby authorize the following payroll action:

Employee Name (First-Middle-Last)

Hendy S. Collins

Employee Social Security Number

Deceaser 20, 1970

Effective Date

Type of Action

024044-5103

Employing Office or Committee/Subcommittee

Assassinations

• Appointment

• Salary Adjustment

• Title Change

E Termination (At close of business on effective date)

• Leave without pay (Beginning with effective date above and ending

close of business_

• (If type of action is an Appointment, Salary Adjustment, or Title Change, complete appropriate information below.)

Position Title

Specify Date

Gross Annual Salary*

* If employee is a civil service annuitant (includes U.S. House of Representatives), the gross annual salary shown should include the annuity received by the employee

plus the salary received from the employing office.

(If Committee Employee, complete appropriate item below.)

1. • Standing Committee: Staff— Clerical or • Professional.

2. 0

Special (Investigative staff of Standing Committee) or Select Committee: Authority—H. Res.20%

_-of 221- Congress.

3. • Joint Committee.

(If Employee of an Officer of the House, complete item below.)

Position Number_.

It applicable, Level

Step_

I certify that this authorization is not in violation of 5 U.S.C: 3110(b), prohibiting the employment of

relatives.

Date__

beca. ber 12g 1970

19

(Signature of Authorizing Official)

(if appropriate, signature of Subcommittee Chairman or Ranking Minority Member)

(Type or print name and title of above official)

(Type or print name of Authorizing Official)

chaintan

(Title - If Member, District and State)

All appointments and salary adjustments for employees under the House Classification Act and for Committee em-

ployees; except those of the Committee on Appropriations; the Committee on the Budget, and the Joint Committees, must

be approved by the Committee on House Administration..

APPROVED:

Office of Finance use only:

Office Code.

Monthly Annuity $

Chairman, Committee on House Administration

ID --

Benefits

Payroll

00

as of --

Copy for Initiating Office or Committee

(Revised: August!

NW 88326

Docld:32243290 Page 4

---

## Page 5

PAYROLL AUTHORIZATION FORM

(Please Use Typewriter

or Ballpoint Pen)

U.S. HOUSE OF REPRESENTATIVES

Washington, D.C. 20515

(Any erasures, corrections, or changes

on this form

must be initialed by the

authorizing official.

To the Clerk of the House of Representatives:

I hereby authorize the following payroll action:

Employee Name (First-Middie-Last)

Effective Date

heady So

collins

Employee Social Security Number

024-44-5163

Racender

208. 192t

Type of Action

Employing Office or Committee/Subcommittee

Essass inacious

#Appointment

I Salary Adjustment

• Title Change

• Termination (At close of business on effective date)

• Leave without pay (Beginning with effective date above and ending

close of business_

(If. type of action is an Appointment, Salary Adjustment, or Title Change, complete appropriate information below.)

Position Title

Specify Date

Gross Annual Salary*

Rescarch Attorney

519,000

* If emoloyee is a civil service annuitant (includes U.S. House of: Representatives), the gross annual salary shown should include the annuity received by the employee*

plus the salary received from the employing office.

(If Committee Employee, complete appropriate item below.)

1. • Standing Committee: Staff—® Clerical or • Professional.

2.10

Special (Investigative staff of Standing Committee) or Select Committee: Authority—H: Res. 263

-_of 2E

Congress.

3. D Joint Committee.

(If Employee of an Officer of the House, complete item below.)

Position Number_

If applicable, Level

Step_

I certify that this authorization is not in violation of 5 U.S.C. 3110(b), prohibiting the employment of.

relatives.

Date_

Lacember 22.

, 19-77

(Signature of Authorizing Official)

(if appropriate, signature of Subcommittee Chairman or Ranking Minority Member)

Louis Sukes.

(Type or print name of Authorizing Officiall

(Type or print name and title of above official)

(Title - If Member, District and State)

All appointments and salary adjustments for employees under the House Classification Act and for Committee em-

ployees, except those of the Committee on Appropriations; the Committee on the Budget, and the Joint Committees, must

be approved by the Committee on House Administration.

APPROVED:

Office of Finance use only:

Office Code.

Monthly Annuity S_

Chairman, Committee on House Administration

ID

Benefits -

Payroll.

00 as of

Copy for Initiating Office or Committee

(Revised: August ! 1977)

NW 88326

Docld:32243290 Page 5

---

## Page 6

C

US: GOVEANMENT PRINTING OFFICE: 1976-599-393

Ÿ336

If typewriter is not available, bear down with ball-point pen to make legible copies.

HEALTH BENEFITS REGISTRATION FORM

FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

(Read instructions on back of page 3.)

New Carrier's Control No.

22933820

Old Carrier's Control No.

1. NAME

TO EMPLOYING OFFICE:

SHOW OLD CARRIER'S CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL

ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN.

(FIRST)

(MIDDLE INITIAL)

PART A

ColliNs

NeNDi

NUMBER AND STREET

ALL WHO REGIS-

TER MUST FILL

IN THIS PART.

4. YOUR MAILING ADDRESS

1630 HobARt Si., N.IU

2. DATE OF BIRTH

(Use numbers)

DAY

22

3. ARE YOU NOW

MARRIED?.

YEAR.

53

(CITY)

(STATE)

(ZIP CODE)

WASHiNgton D.C.

20009

MONTH

03

b. SOCIAL SECURITY

ACCOUNT NUMBER

024-44-5163

Yes

No

MALE

FEMALE

IT ISILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF YOU ARE ALREADY COVERED THROUGH

THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER

ENROLLMENT MUST BE CANCE LED OR CHANGED TO SELF ONLY: SIMILARLY, IF A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR HER) OWN

ENROLLMENT, YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT.

ALSO SEE BACK OF PAGES. 2 AND 3.

PART B

FILL IN THIS

PART IF YOU

WISH TO ENROLL

OR CHANGE

YOUR ENROLL

MENT IN A

HEALTH. BENE-

FITS PLAN.

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.)

Blue Cross/ Blue Shield Service

HIGH

Benefit

22s pace below listed eligible fad ily embers without exception: List vour wife or husband first, then your unmarried children under age

adopted children and (b) stepchildren;

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

ELIGIBLE FAMILY MEMBERS.

disabled child age 2 or veNOT RECEIVE BENEFITS.

ARE DEPENDENT ON YOU AND ARE LISTED.

DATE OF BIRTH'

NAMES OF FAMILY: MEMBERS

(Month, Day, Year)

NAMES OF FAMILY MEMBERS

DATE OF BIRTH

(Month, Day, Year)

If enrollment is

for Self Only,

answer item 1.

Ifenrollment.is

for Self and

Family, also an:

•swer item 2.

wite or

Husband

3

IF.YOU ARE

CHANGING YOUR

ENROLLMENT

ALSO FILL' IN

PART D:

PART C

FILL IN THIS

PART

IF YOU

WISH NOT

ENROLT

TO

OR. IF

YOU WISH

CANCEL

YOUR

ENROLLMENT.

PART D

FILL"IN THIS

PART, AS WELL

AS PART B. TO

CHANGE YOUR

REGISTRATION.

PLACE AN "X". IN ITEM 1

OR 2 WHICHEVER APPLIES:

I ELECT NOT TO ENROLLIN A PLAN UNDER THE FEDERAL

EMPLOYEES HEALTH BENEFITS PROGRAM:

2. 1 ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THE.

CODE NUMBER SHOWN BELOW•

Present Enrollment Code Number.

If you elect to cancel

be sure to read

"Cancellation of Enroll-

ment" on back of page 3.

ANSWER. ITEMS 1,2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE.

.1.

ENROLLMENT CODE NUMBER

, NUMBER OF EVENT WHICH PERMITS CHANGE

3. DATE OF EVENT WHICH PERMITS CHANGE.

OF PRESENT-PLAN.

(See table on back of page 2 for proper number.).

MONTH

DAY

YEAR

PART E

ALL WHO REGIS.

TER MUST FILL

IN THIS PART.

Wendy SCallen

lATURE. DO NOT PRINT

. NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICE

Ang 5,1975

(DATE)

WARNING.- Any intentional false statement:

in this application or wilful 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.)

2. DATE RECEIVED IN

3.

EFFECTIVE DATE OF

EMPLOYING OFFICE

ELECTION

PART F

TO BE

COMPLETED

BY AGENCY

U.S. House of Representatives

Office of Finance, Washington, D.C.

20515

4. PAYROLL OFFICE NO.

5. SF 2811 REPORT NO.

00004832

. (SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)

REMARKS

FOR USE ONLY

BY AGENCY.

NW 88326

Docld:32243290 Page 6

Standard Form No. 2809

Civil service commission;

Page 1 - To Payroll Ortice

---

## Page 7

If typewriter is not available, bear down with ball-point pen to make legible copies.

HEALTH BENEFITS REGISTRATION FORM

New Carrier's Control No.

A FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

(Read instructions on back of page 3.)

22933820

Old Carrier's Control No

TO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL

ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN.

(FIRST)

(MIDDLE INITIAL)

1. NAME

(LAST)

PART A

ColliNs

NenDy

(NUMBER AND STREI

ALL WHO REGIS.

TER MUST FILL

IN THIS PART.

4. YOUR MAILING ADDRESS

51 ,

N.W

YEAR

53

1630 ItobARt

(CITY)

(STATE)

(ZIP CODE!

WASHiNgton D.C.

2000%

2. DATE OF BIRTH

(Use numbers)

MONTH

DAY

03

22

5. SOCIAL SECURITY

ACCOUNT NUMBER

024-44-516

3. ARE: YOU NOW

MARRIED?

Yes

No

6. SEX:

MALE

FEMALE

IMPORTANT

IT IS ILLEGAL FOR AN EMPLOYEE ÓR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT.

IF YOU ARE ALREADY COVERED THROUGH

THE FAMILY ENROLLMENT OF

ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER

ENROLLMENT MUST BE CANCE LE DOR CHANGED TO SELF ONLY.

SIMILARLY, IF A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR HER) OWN.

ENROLLMENT; YOUCANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES.2 AND. 3.

l elect to enroll in a health benefits plan as shown below. I authorize deductions from my salary, compensation, or annuity to cover-my

PART B

FILL IN THIS

PART IF YOU

WISH TO ENROLL

OR CHANGE

YOUR ENROLL

MENT: IN :A

HEALTH BENE

FITS PLAN.

share of the cost of the enrollment.. (Copy the information requested below from back page of brochure of, the plan you select.)

7 OPTION (HIGH OR LOW) ENROLLMENT CODE NUMBER

NAME OF PLAN

Blue (ross/ Blue Shield

seRvice

HIGH

O

/

Benefi

PlAN

In space below list all eligible family

members without exception: List your wife or husband first, then your unmarried children under age

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

incapable of self-support

certificate for

• PARENTS

ARE NOT ELIGIBLE FAMILY MEMBERS

I MENSES THE WiL NOT RECEIVE SEE FiT VEN IP THEY

ARE DEPENDENT ON YOU AND ARE LISTED.

DATE OF BIRTH

NAMES OF FAMILY MEMBERS

NAMES OF FAMILY MEMBERS

(Month, Day: Year)

DATE OF. BIRTH

(Month, Day. Year!

If enrollment is

for Self Only,

answer item 1:

If enrollment is

for. Self

and

Family, also an

swer item 2.

Wife or

Hussano

IF YOU ARE

CHANGING YOUR

ENROLLMENT

ALSO FILL IN

PART D:

3

4

5

PLACE AN "'X" IN ITEM 1 ÖR.2 WHICHEVER APPLIES

PART C

1. I ELECT NOT

TO ENROLL IN A PLAN UNDER THE FEDERAL

FILL IN

PART

THIS

EMPLOYEES HEALTH BENEFITS PROGRAM

IF YOU.

WISH

NOT TO

ENROLL OR IF

YOU WISH

TO

'CANCEL YOUR

ENROLLMENT.

PART D

FILL -IN THIS

PART, AS WELL

AS PART. B - TO

CHANGE YOUR

REGISTRATION.

ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THI

ODE NUMBER SHOWN BELOW

Present Enrollment Code Number

If you elect to cancel

be sure to read

"Cancellation of Enroll-

ment on back of page 3.

ANSWER ITEMS 1, 2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE.

ENROLLMENT CODE NUMBER

NUMBER OF EVENT WHICH PERMITS CHANGE.

3. DATE OF EVENT WHICH PERMITS CHANGE

OF, PRESENT PLAN

(See table on back of page 2 for proper number.)

MONTH

DAY

YEAR

PART E

ALL WHO REGIS-

TER MUST FILL

IN THIS PART.

allen

IYOUR SI

NATURE. DO NOT PRINTI

NAME AND ÄDDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICE

Ang 5, 1978

WARNING. - Any intentional false statement

in

this application or wilful 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.)

2.

RECEIVED IN

EMPLOYING OFFICE

3.

EFFECTIVE DATE OF

ELECTION

PART F

TO BE

COMPLETED

BY AGENCY

V.S, Rouse of Representatives

Office of Tinance, Washington, D.C.

20515

A. PAYROLL OFFICE NO.

5. SF 2811 REPORTNO.

00004832

ISIGNATURE OF AUTHORIZED AGENCY OFFICIAL!

REMARKS

FOR USE ONLY

BY AGENCY.

NWV 88326-

Docld:322432901 Rage 7

Page 2 - To Insurance Carrier

Standard Form No.

2809

U.S. Civil Service Commission

---

## Page 8

If typewriter is not available, bear down with ball point pen to make legible copies.

HEALTH BENEFITS REGISTRATION FORM

* FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

(Read instructions on back of page 3.)

New Carrier's Control No.

22933820

Old Carrier's Control No.

TO EMPLOYING OFFICE: SHOW ÖLD CARRIER'S CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL

ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN

I NAME

(LAST)

(MIDDLE INITIAL)

2. DATE OF BIRTH

3: ARE YOU NOW

PART A

Collin.

(Use numbers)

MARRIED?

MONTH

DAY :

YEAR

ALL WHO REGIS-

4. YOUR MAILING ADDRESS

TER MUST FILL.

N.lJ

63

22

S:

Yes

NO

IN THIS PART.

(STATE)

(ZIP CODE)

5. SOCIAL' SECURITY

6. SEX

DO

2000%

ACCOUNT NUMBER

MÄLE

FEMALE

IMPORTANT

IT IS ILLEGAL' FOR AN EMPLOYÈE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT: IF YOU ARE ALREADY COVERED THROUGH

THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR' ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER

ENROLLMENT MUST BE CANCE LED OR CHANGED TO SELF ONLY.

SIMILARLY, IF A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR HER) OWN

ENROLLMENT, YOU CANNOTELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMEN.T.

ALSO SEE BACK OF PAGES 2 AND 3:

PART. B:

1. l elect to enroll in a health benefits plan as shown below. I authorize déductions from my salary, compensation; or annuity to cover my.:

share of the cost öf the enrollment. (Copy the information requested below from back page of brochure of the plan you select.) •

FILL IN THIS

PART. IF

YOU

WISH TO ENROLL

Blue

/ Blue Steels

Sovie

HIEN

OR CHANGE

YOUR ENROLL-

In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age

legally adopted children and (b) stepchildren,

MENT

IN A

HEALTH BENE

FITS PLAN.

ARE DEPENDENT ON YOU AND ARE LISTED.

If enrollment is

for Self Only,

answer itém 1.

If enrollment is

for Self and

Family, also an.

swer item 2.

NAMES OF FAMILY MEMBERS:

DATE OF BIRTH

(Month, Day. Year)

NAMES OF FAMILY MEMBERS

DATE OF BIRTH

(Month, Day, Year)

Wife or

Husband

3

IF YOU ARE

CHANGING YOUR

ENROLLMENT.

ALSO FILL: IN.

PART D.

PART C

FILL ' IN

THIS

PART: IF.

YOU

WISH NOX TO

ENROLL OR IF

YOU WISH

TO

CANCEL YOUR

ENROLLMENT.

PLACE AN A INHIEMTON<WHICHEVEn ArrLIEo:

ELECT.NOT TO ENROLL IN A PLAN UNDER THE FEDERAL

•EMPLOYEES HEALTH BENEFITS PROGRAM.

I ELECT TO

CANCEL MY PRESENT ENROLLMENT UNDER THE:

CODE NUMBER SHOWN BELOW

Present Enrollment Code Number

If you.elect to cancel

be sure to read

"Cancellation of Enroll-

ment" on back of page 3.

PART D

FILL IN THIS

PART, AS WELL

AS PART B. TO

CHANGE YOUR

REGISTRATION.

ANSWER ITEMS 1, 2. AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE:

.:,ENHOLLMENT CODE NUMBEH

NUMBER OF EVENT WHICH PERMITS CHANGE.

3. DATE OF EVENT WHICH PERMITS CHANGE.

OF PRESENT PLAN

(See table'on back of page 2 for proper number.)

MONTH

DAY

YEAR

PART E

ALL WHO REGIS.

TER MUST FILL

IN THIS PART.

Fing 5, 19

(DATE)

78:

(YOUR SIGNATURE. DO NOT PRINT)

NAME AND ADDRESS (INCLUDING ZIP CODE). OF EMPLOYING OFFICE

WARNING.- Any intentional false statement

in this application or wilful misrepresentation

relative

thereto. is

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.

DATE RECEIVED IN

3. EFFECTIVE DATE OF

EMPLOYING OFFICE

ELECTION

PART F

TO BE

COMPLETED

BY AGENCY

Representatives

Rashtogtoe,

D.Ge

20035

4. PAYROLL OFFICE NO.

SF 2811 REPORTNO.

000003

(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)

REMARKS

FOR USE ONLY

BY AGENCY.

"NW 88326-

Docld:32243290' Page 8

Page 3 - For Official Personnel Folder

Standard Form No. 2809

Civil Service Commission

---

## Page 9

If typewriter is not available, bear down with ball-point pen to make legible copies.

HEALTH BENEFITS REGISTRATION FORM

¡FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

(Read instructions on back of page 3.)

New Carrier's Control No.

22933820

Old Carrier's Control No.

TO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL.NUMBER ONLY IF ELECTION IS TO CANCEL

ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF, ENROLLMENT IN THE SAME PLAN.

(LAST).

(FIRST)

PART A

ALL WHO REGIS-

4. YOUR MAILING ADDRESS

• (NUMBEH

AND STREET)

TER MUST FILL

IN THIS PART.

(MIDDLE INITIAL)

2. DATE OF BIRTH

(Use numbers)

MONTH

DẠY

3 ARE.YOU NOW

MARRIED?

YEAR

Yes

No

12"

ZIP CODE)

5. SOCIAL SECURITY

ACCOUNT NUMBER

6. SEX

MALE

FEMALE

IMPORTANT

MITISILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF. YOU ARE ALREADY COVERED THROUGH:

THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR: DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST: REGISTER NOT TO ENROLL OR THE OTHER:

ENROLLMENT 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) OWN

ENROLLMENT, YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES 2 AND: 3.

PART B

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.)

FILL IN THIS

NAME OF PLAN

OPTION (HIGH OR LOW)

ENHOLLMENT CODE NUMBER

PART

IF

YOU

WISH TO ENROLL

OR CHANGE

YOUR ENROLL-

222, including ali tell gile fed hildren end with steenition

List your wife or husband first, then your unmarried children under age

foster children,

and illegitimate children who live with you in a regula

MENT. INA

parent-child relationship. Include also any unmarried child over 22 who became disabled before age 22 and who, because of the disability

HEALTH BENE-

PARE OR OTHERS WHO ARE NO EL GEE MIME MEE PEE BE EVEN NO THEY

FITS PLAN:

ARE DEPENDENT ON YOU AND ARE LISTED.

NAMES OF FAMILY MEMBERS

DATE OF BIRTH

DATE OF BIRTH!

(Month, Day, Year)

NAMES OF FAMILY MEMBERS

(Month, Day, Year).

If enrollment is

for Self Only,

answer item 1.

If enrollment is

for

Self and

Family, also an

swer item•2:

IF YOU ARE

CHANGING YOUR

ENROLLMENT

ALSO FILL IN

PART D.

PART C

FILL IN:

THIS

PART: IF

YOU

WISH. NOT TO

ENROLL

OR IF

YOU WISH

TO

CANCEL YOUR

ENROLLMENT

PART D

FILL IN THIS

PART, AS WELL

AS PART B, TO

CHANGE YOUR

REGISTRATION.

PART E

ALL WHO REGIS.

TER MUST FILL

IN THIS PART.:

PART F

TO BE

COMPLETED

BY AGENCY

REMARKS

FOR USE ONLY

BY AGENCY.

2809-115-01

vite oi

Husband

3

8

9

PLACE

AN":X" IN ITEM 1 OR 2 WHICHEVER

"'ELECT NOT TO ENROLL IN A PL

UNDER THE FEDERAL

EMPLOYEES HEALTH BENEFITS PROGRAM.

I ELECT TO CANCEL MY PRESENT ENROLLMENT. UNDER THE

CODE NUMBER SHOWN BELOW:

Present Enrollment Code Number

If you elect to cancel

be sure to read

"Cancellation of Enroll.,

ment"' on back of page 3.

ANSWER ITEMS 1, 2, AND 3 TO SHOW ENROLLMENT CODE .BEING CHANGED AND ELIGIBILITY FOR CHANGE.

1.4

- ENROLLMENT CODE NUMBER

NUMBER OF EVENT WHICH PERMITS CHANGE: 3. DATE OF EVENT WHICH PERMITS CHANGE:

OF PRESENT PLAN

(See table on back of page 2 for proper number.)

MONTH

DAY

YEAR

(YOUR SIGNATURE-

10! |IN1

1: NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICE:

75

WARNING.- Any intentional false statement

in

this application or wilful 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.)

DATE:RECEIVED IN

3. - EFFÉCTIVE DATE OF

EMPLOYING OFFICE

ELECTION

Dole

4: PAYROLL OFFICE NO.

5. SF 2811 REPORT NO.

(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL).

Page 4 - To Enrollee

Standard Form No. 2809

Supplement 890-1

November 1972

-N 88326

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Best image possible.

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## Page 10

PAYROLL INFORMATION FORM AND PERSONNEL AFFIDAVIT

PLEASE USE TYPEWRITER OR PRINT IN INK

CODE:

Finance Office Use Only

U.S. HOUSE OF REPRESENTATIVES

Name

ColliNS, IN W

WenDy SuSAN

Social Security No. 024-44-5/63

4.5. House

Employing Office

Select ComMittee on

ASSASSINATIONS

Date of birth

03-22-53

Month Day Yea:)

Mailing address for withholding tax statement:

1630 HubARt St., N.WV.

WASHINgtOn, DiC 2000%

FINANCE OFFICE USE ONLY

Bank Code: _

ADDRESSES®

Mailing address for payroll check (Bank home, pfice, etc.):

SelECt COMMIHGRON ASSASSINATIMS

Horise Anwex 72 -RM

WASH., DiC Si: 20515

Bank Account No.

(Do not. insert. Bank Account Number unless checis

is to be mailed to a bank)

23310101

PREVIOUS FEDERAL CIVILIAN SERVICE

• House of Representatives- Office of

• Other Federal Departments (including Senate and Architect)

Agency'

Separation date of last service

• Name (if different from present signature)

While employed as above I was covered by:

1*97

Federal Employees' Health Insurance:

enrolled; E not enrolled, • excluded.naz

Federal Employees' Life Insurance: optional; [ regular; ivaived; ™ excluded.

ELECTION OF RETIREMENT COVERAGE

Coverage under the provisions of the Civil Service Retirement Act is extended to employees of the House

of Representatives on a voluntary basis. Once you have elected this coverage and retirement deductions

have been withheld, such deductions cannot be discontinued so long as you are continuously employed

under the Act.

Check the appropriate box to the right:

YES

I elect coverage under the provisions of the Civil Service Retirement Act and request that deduc-

tions begin at the earliest possible date. (If you have had previous Federal or Military service;

please submit dates, Agencies and Military Serial Number on a separate sheet.)

1 do not wish to elect coverage under the Retirement Act at this time.

NO

(Note: Legislative employees are not covered by the Social Security Act.)

Collim

(Signature)

(Over)

16-82058-1

NW 88326

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## Page 11

District of Columbia (or State-of)

SS:

I do solemnly swear (or affirm) -

(1) That

I am a citizen of the United States;

if in the service on the date of enactment of the latest General Government Matters

Appropriation Act, and being eligible for citizenship, I had theretofore filed a declara-

tion of intention to become a citizen;

• I owe allegiance to the United States;

'[ Iạm an alien from Poland or the Baltic countries lawfully admitted to the United States

for permanent residence;

I am'a citizen of the Republic of the Philippines;

I am a national of a country allied with the United States in the current defense effort;

(2) That my acceptance and holding of office or employment with the U.S. House of Representatives

does not or (if this affidavit is executed by me prior to my acceptance of such office or employment) will

not constitute a violation of the first section of the Act of August 9, 1955 (5 U.S.C. 7311), which reads as

follows:

No person shall accept or hold office or employment in the. Government of the United States or any agency thereof,

including wholly owned Government corporations, who-

- (1) advocates the overthrow of our constitutional form of government in the United States;

is a member of an organization that advocates the overthrow of our constitutional form of government in the

United States, knowing that such organization so advocates;

(3) participates in any strike or asserts the right to strike against the Government of the United States or such

(4) is a member of an organization of Government employees that asserts the right to strike against the Govern-

ment of the United States or such agencies, knowing that such organization asserts such right;

(3) Thạt I

Yam not receiving a pension, annuity, or retired pay from the United States

Government (if so, please furnish source and claim number);

(Name and location of administering agency)

(Claim number)

(4) That this Payroll Information Form and Personnel Affidavit is complete, true, and correct;

(5) That I will support and defend the Constitution of the United States against all enemies, foreign

and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely,

without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the

Subscribed and sworn to before me this

st

31

day of

bonds Call

of employee)

19.28

NOTARY

SEAL

15-82

My commission expires .

U.S. GOVERNMENT PRINTING OFFICE 1682058-1

NW 88326

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## Page 12

W.S. House of Representatives

OFFICE OF THE CLERK

OFFICE OF FINANCE

IMPORTANT NOTICE TO EMPLOYEE

Newly employed personnel must execute the attached combined PAYROLL INFORMATION FORM

and PERSONNEL AFFIDAVIT properly and submit them to the Office of Finance, where a Notary Public

is on duty to perform this service without charge. DO NOT SIGN PERSONNEL AFFIDAVIT UNTIL BEFORE

A NOTARY.

Currently employed personnel wishing to make changes in their records need only complete the perti-

ment section of the PAYROLL INFORMATION FORM, indicate their employing office, and affix their signa-

ture. Please be certain that information is legible enough for the Finance Office to identify the individual

making the change.

DETACH AND RETAIN THIS NOTICE

Salary payments are made by check monthly and mailed to the address designated on the Payroll

Information Form. Checks are disbursed from the Office of Finance to normally reach the addressee on the

last working day of each month.

For additional information, contact the Office of Finance, 263 Cannon Office Building, Telephone

Extension 56515 or 57064.

EMPLOYEE BENEFITS

RETIREMENT: An employee of the House of Representatives is eligible to join the Federal Civil

Service Retirement System. Participation is voluntary, and action to elect retirement coverage may be

initiated at any time by completing the appropriate section of the Payroll Information Form. Once an

election is filed and the normal deduction of 7½ percent of the gross salary commences, the employee

cannot discontinue deductions so long as he is continuously employed. (Note: Legislative employees are

not covered by the Social Security Act.)

LIFE INSURANCE: An employee is automatically covered under the Federal Employees' Group

Life Insurance Act unless he waives or subsequently cancels such coverage by filing the required waiver

form with the Office of Finance. The insurance coverage is $10,000; or an amount equal to the gross annual

salary, rounded to the next higher thousand dollars (if the salary is not a multiple of a thousand dollars),

plus an additional two thousand dollars; whichever is the greater. Additional optional insurance coverage

in the amount of $10,000 is also available.

HEALTH BENEFITS: The Federal Employees' Health Benefits Program is available on a voluntary

basis with costs partly financed by the Government. Within 31 days after the effective date of appointment,

every employee must register to enroll in a plan or not to enroll. Future opportunities to enroll or to change

the type of enrollment are shown in the enclosed pamphlet. Also enclosed is the necessary registration form,.

Standard Form 2809.

U.S. SAVINGS BONDS: Monthly deductions for bonds in regular bond denominations may be

authorized. Authorization cards are available in the Finance Office.

WORK INJURY BENEFITS: An employee injured or incurring disease as a result of performance

of duty is entitled to medical care and monetary benefits under the provisions of the Federal Employees'

Compensation Act. In instances where such injury or disease is fatal, the employee's family is entitled to

monetary benefits. The Compensation Act is administered by the Bureau of Employees' Compensation,

U.S. Department of Labor. Forms for filing notices of injury and claims for compensation are available

in the Office of Finance or from any Postmaster.

UNEMPLOYMENT COMPENSATION: An employee may under certain circumstances be entitled

to unemployment compensation if discharged or otherwise separated from his employment. The com-

pensation is usually payable by the State (including the District of Columbia) in which the employee had

his last service. However, a claim for benefits may be filed in the local office nearest the employee's

residence. If an employee is discharged for misconduct, quits voluntarily without good cause, or refuses a

suitable job without good cause, then there is a period of disqualification which varies from State to State.

The amount of payments and period of time payable also varies from State to State.

1682058-1

NW 88326

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## Page 13

MEMORANDUM

TO: Thomas Howarth, Budget Officer

Elizabeth Berning, Chief Clerk

FROM: I. Charles Mathews, Special Counsel

DATE: December 19, 1977

RE: Ms. Wendy Collins

Please be advised that Ms. Wendy Collins has

accepted the position of Senior Attorney Researcher with

the Select Committee on Assassinations. Her effective

starting date will be December 29, 1977 and her

starting salary will be $18,000.00.

Your full cooperation will be appreciated in

familiarizing her with staff procedures and welcoming

her aboard.

ICM: j1

NW 88326

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## Page 14

MEMORANDUM

TO: ALL STAFF

RE: Payroll Certification

The Regulations and Accounting Procedures for Allowances and

Expenses of Committees, Members and Employees of the U.S. House of

Representatives require that, among other things, the Committee's

monthly payroll certification include the relationship, if any, of

each employee to any current Member of Congress. This certification

is signed monthly by our Chairman.

The following are the relationships to be included in the

certification:

father

mother

son

daughter

brother

sister

uncle

aunt

first cousin

nephew

niece

husband

wite

father-in-law

mother-in-law

son-in-law

daughter-in-law

brother-in-law

sister-in-law

stepfather

stepmother

stepbrother

stepsister

half-brother

half-sister

Please complete the appropriate portion below, sign and date

this form, which will then become a part of your permanent personnel

file.

If this status changes, you must notify the Committee's Budget

Office immediately of the change.

I am not related to any current (95th Congress) Member of Congress.

I am related to a current (95th Congress) Member of Congress.

(Please specify.)

Wendy

Signature of

Employee

29 Der 77

Date

NW 88326

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