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ren er * \LVH BENEFITS REGISTRATION FO. weibid va rst ' FEDERAL EMPLOYEES HEALTM SENEFITS ACT OF 1959 1 Grad sete ! (Rent -~vctians an back of last page. Use only typewriter or b: ~~ l' Name AST, (FIRST) (MIDDLE INITFAL) 2. De PART A Hoover J. Edgar ALL wiio _ ee REISER 4. YOUR MARING ALOKESS (NUMBER AND STREET) ICtY AMD LONE NUMBER) muST FIL 4936 30th Place, N. W. Washington & D. C. aw THis 6. Are you covered by, o is any family member listed below cov- Pat. ered by or enrolling in, @ plan vader the Federal Employees Health Benefits Act of 1959 [through the enrollment of another . . : United States or District of Columbia Government! employee or unots s4.000 [FT | - $4200 © .900 TA . onnuitont|? vs[] we [ $4,000 10 $5,999 ["J3] ° s10,009 cn own (58S) b. 1 elect4e anroil in o health benefits plon a1 shown below, | autharize deductions to be made from my sclory, epeapensaliqn, or lo tower my shore of the cost of the enrollment. Copy the information recwested below fre below from inside cover Wlecueabalontatocd ne ee — aa —+ pen. | . OF RRTH “TSTATE) 7. Ploce an “X"' in proper be ronge. PART B FILL WW THIS PART HF YOU WEALTIN BENEFITS rae ann ev ee PLA, In spoce ce below” Th t oll <igibte family members without exception: List y your wife or husbond Ars ret, then your unmarthed Thien wee age 19, including legally adopted children, and stepchildren and illegitimate children whe live with you ino regular quvent-chlld egintien- | ship. ‘nelude also ony unmarried child over 19 who becamp disabled before oge 19 and wha, becouse of the ceably, is inenpable of self-tupport. (Attach a doctor s certificate for a duabled child age 19 or over.} Seer —_=—-- { eee ee aero | ee = - SATE Of path it E t TH PaaTt MUST ALSO BE FILLED Hoyo are o female [employee or aniwitont)—does the i. mity tated above include @ hutand whe is incapable of mei, | = 7] support by tecton of mental or physical disability which can be expected to cuntinue for more thon one year? = (ff enewer . is "Yes," attach @ docior’s certificate.} iat ont oi eae AN "KR" IN ITEM t O8 ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 9. FILL Sv THIS. . Lele not t enroll ia any plen 3. The mason for my election is (Place an 'X"” in proper bos): a 2 PART IF YOu under the Heclth Benefits Act. {a} fom covered tye plan under -the-Kealth enebinsct merge the enn... £ YS}! wt NOT To mant of my husbund, wile, or parent. han 106 wise te . Select to concel my present enroll: ib) Lem covered by a heotth uniuronce plon which ib not under the Loa “Oe cr CANCEL YOUR Berelity Act. . (c] Any other reason. ; wt EMEOLLALENT , PART D Tl Ae THES PART iF YOU wish To CHANGE YOUR ERDL LENT. PART E . Number of ‘event peent which permits change. Glee table on tock af duplicom bo mopar aber.) i. Enroliment code | number of present pian. AL WHO . REGISTER ; must rt 4 re 2, - 6/3/00 sh THIS PART. (TOUR $iGeATURE—+ 00 NOT PRINT) oo tare) Ba FEDERAL BUREAU OF INVESTIGAT UNITED STATES DEPARTMENT OF JUSTICE WASHINGTON 25, D.C. {HONATURE OF AUTHOMIZED ASEH! OFFiciaal REMARKS Tue USE ONLY BY AMMUITANTS anD AGENCY. = rein a 2 pty wd - “toe oo” nance tee ST et pear Pee Qe pe ae te mye npn oe amma ee AIT ETS ENT Ee ?