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ae UNITED STATES DEPARTMENT OF JUSTICE FEDERAL BUREAU OF INVESTIGATION ere In Reply, Piase Refer to File No, foarre ota! Federal Burr 2 of Investigator Un jted States Teparmment of Justice RE: Se d Washingicn, > . <. {Type or print plainiy} Dear Sir: Forctrcissien in the fund to be paid to the designated beneficiary of any Special Agent of the FB! whe has previously centnibired + his fund and who dies from any cause excep! self-destruction while employed ae a Special Agent, | am tor- wa: ing herew'th (by Check - Money Order) the sum of $10, payable to the Assistant Director, Administrative Division, FET, to be included i: gaia fund, Payment will be made for death by seli-destruction atier the Agent has been a member of the fund tur a cantir uous period of two years, It is understoud and agreed that the sum tendered herewith is a voluntary, gratultous contribution te said fund which ? understand ts to be administered in the following manner. The Director of the FRE wil! appoint a committee which shail consider all matters pertaining to the acquisition, sate keejcng and espending of said tung, which committee wiil recommend appropriate action to the Director in pertinent matters The Assistant Director of the Administrative Division of the FRI shall receive all] contributions and account for same to the Director, ‘on the death of any Special Agent who is a member cf said fund the appointed committee will congider the case and Submit ad recosnmendoation to the Director ae to ite conclusions. Appropricte ingtructiongs will then be issued to the A asist- ant birectur uf the Administrative Division, directing him to pay to the designated beneficiary the sum of $10,000, Tie liability cf the tund erali not under any citcume@tances exceed the amount of monies in the fund at the time any liability shall occur, The tollowing .erson 18 designated as my benefictary tor FB] Agents’ insurance Funda: Relationship Name (primary beneficiary) Address Tontingen” beneficiary, if destred} Estate Nan. Address The toliowing person is designated as my beneficiary under the Chas, 5, Ross Fund providing $1500 death benefit to beneficiary of agents killed in the line of duty, other than travel accidents. Nan.@ (primary beneficiary) Relationship Estate 9-5-62 Address Relationship Name ,contingyvnt beneficiary, if aon state 9-5-6272 Address Very truly yours, 1 fay ape Swe wear te omen Tee TD “y me