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F.I.... SON CONCERNING DEPENENC CHLD! _OF THE DECEASED C THC LELLASEDVHO WEAE URIDER ACE 1A AT THE TIME RRDEATH.CLUDE LECALLY ADOPIED AND IDCE AFRTHR NAMES HA THY AXE AU .LLEGIMATE. OR STtPCHILOREN. I: ) .:.! ) Ci+.L. I ACE t3 AND 22 WHO IS A FULL-TIME SFUD.NT II A RCCOCrHZEO tOUCAHONAL INSIIUHION, WRIE THE WORD UL.. 10:10 i AL 2 UI 1E ILJHIC JUr 1. IQWVER, YOU LISI SUCH A CIHLD, C SURE TO SHOW HS ACTUAL DAIE OF BIRIH.) Ir. iU.t AL) :+Y U::t t .C Ci!D OVL< 13 H!O DLCAME DISAELSD S.FC:E ACE 18 AHID WHO, GECAUSE Of THE DISABILITY, IS INCAPABLE OF SELP-SUPPORI, E IE VCRU CiSIE AIL SUCH CHLD'S NAME AND ATIACH A SEPARATE SHCEI CIVIC FULL PARTICULARS ACOUT THE DISABITY. DID CHD RECEIVE DATE OF CIRTH #ULL NAE OF CHD MORE TIAN ONE- NAME AND ADDRISS OF PEASON WIO HOW HAS THE (Monsh)(sy)(Yer) CHILD AND HIS OR HERRELATIONSHIP TO THE CHILD FROM DCFASEO? none YES IF A!IY STEPCHILD CR HIECITIMATE CHILD LISTEO ADOVE WAS NOT LIVINC WITH THE DECEASED AT THE TIME OF HIS OR HER) DEATH, 3.IS THERE AN UNSORN CHLD CIYE NAME OF CHILD AN EXPLAIN BRIEFLY WHY THEY WERE LIVING APART OF THE DECEASED? ] rts [] n0 4IF A GUAKOIAN HAS BELN APO.NIED EY THE COURT FOR ANY OF THE CHILDREN LISTED ABOVE, CIVE GUARDIAN'S NAME AND .A GUARDIAN HAS NOT ADORESS. BEEN APPOINTED, WH ONE APFOINTED? HASE ADORESS yEs LIST LOW THE NAAE.AGE,EIC.OF THE DECEASEOS WICOW OR WIDOWER. OR CHILDREN. IF IIEE ARE NO CHHDREN OR DESCEIDANTS OF CECEASD CHILDREN LIST THE OECEASEDS PARENTS IF IVING,BROTHERS,AND SISTERS.AND DESCENDANTS OF ANY CLCEASCD BRTHES AND SISIERS NCICATE WHEIHLR THE BROIHERS ANID SISTERS ARE OF WHOLE OR HALF OOD WHEN COTH DECREES OF KINSHP ARE INVOLVIO.) . IHEA ARE NO SURVIVORS WITHIN THE LtGREES INECATED iN 1.2, AND3,LIST THE HEIRS WHO CAN INHERIT FROM TE DECEASED. NAME RELATIONS!IP TO CECEASED AOROOS (see attached) G. CERTIFICATION WAK NING.-- Any intentionat false state- I hereby certify that al! statements made in this application ase irue to the ment in this applisation or silltut nisregre. best of ny knowledlge, infornation, an! belief, and that no evidence necessary scutation relatie thereto is a violation of'the to a seutleinent of this'claim is suppressed or withheld. law punish.ble by a fine of not nore dan $t0,coo or imprisonuent of not mure than 5. SICNATURE OF APPLICANT DATE years,or both.8 U.S.C.1001.) 7-14.73 Clyde A..Tol,son NOTICE THONE NUMBER, INCLUDING Forward application to the Bureau of Re.. Personal Trust Div., P.0. Bsx ll49. tireumrnt, Insurance, and Occupational Health, Urired States Civil Service YSATE,ANOCODE Conmission, Washingon, D.C. 20115. Washington, D.C. 20013 Attn: Mr. Brewer # INFORMATION FOR THE APPLICANT IF ASSISTANCE IS NEEDED EVIDENCE REQUIRED If you need assistance in completing this application, con- There anust be submited with this application a cerified tact the personnel offie of the department or agency in which. topy of the public rerord showing the death of the employer the deceascd was employed, the nearest tegional office of che or annnitant. lailure to sulnit such death certifcate will United States Ciil Service Commission, or the Bureau of. detay seutlement of claim. Retirenent, Insurance, and Occupational Health, United States. Civil Service Conmission, Washington, D.C. 2o415. Any other nvvesary evidence not of record in the United States Cisil Scrvire Commission will he reyuested atter re. HINAL DETERMINATIONS eeipe ot this applivation. Upon reccipt of this application, the United Scates Civil Sersice Conniission will' determine what benefits, if any, are payable, the amount of such henchits, and co whosn thcy are payable. The Commission will inform dhe applicant of the. Gnal deternination. GOVEEHMENT PRIMTING 70F-393-43724K