Retirement, 5 September 1978

Produced by optical character recognition, uncorrected. These are carbon copies and mimeographs from 1941–46, so the reading is rough — treat it as a finding aid for search, not as a transcript. The scan above is the record.

Reserved for Service Use On,

SURVIVOR BENEFIT PLAN
ELECTION CERTIFICATE

SECTION |
Tast name, Grat, ME

3 Baie of bith

SECTION I. MARITAL, DEP

‘Ave you meried? =) Yes ,
7. Do you have dependent children? S Yes No iset te: provideran:anaulty based
8 Check one of the following to Indicate the type of coverage you desire: & Si cae ran,
8. Spouse only = pay?
Seow and elven % | Fu RepuceD
© Children only oO
4. Natural person with insurable interest oe vou wet 8 pron das endured
(may be elected only if you have no. ay (base amount) upon which you

rant the ennuity computed

$—s¢0300——

spouse and/or children)

None oO

IMPORTANT: ‘The decision you make with respect to participation in this Survivor Benefit Plun is a permanent irrevocable
decision, Please consider your decision and its effect very carefully.

SECTION Ill. FAMILY INFORMATION (List edditional names on reverse)

TO. Nowe of spouse (Lest, first, TH. Spouse Social ‘Spouse date of birth
spouse (Last, First, ML) Spouse See 12
13, Piste enibey Gio] County, State, Country) HIOEMESAS Ph Dow Ege

BoP Ria Theta tar eter BED and Incapable of sei ABA ROMS of @

disability incurred before age 18 or, after age 18 but before age 22 while attending school).

ie, 6st, 150. Sociat Asc, Date of birth | 154 Relationship (natural,

15a, Last
‘ Security No step. adopted, foster)

SECTION IV. INSURABLE INTEREST COVERAGE
16. If you are unmarried and have no dependent children, and you checked item 84, complete this section with information|
pertuining to the person you want to receive an annuity who has an inturable interest in you.

aa 17a, Social Security No, [17. Relationship

Te. Mailing address 17a, Date of birth

ti a oalyalacion coverage ou have avbailiad under the sew Surviver Hecotlt Plan?

(ves Cl) No

5 SECTION VI SIGNATURES,
Signature of retiree Signature of witness

Ab 4. Choo
DD .*°**.1883 PAE Gied RDITIRN MAY BE LAER

— — —

Monthly Cost and Annuity

Spouse only (no eligible children}. Cost of coverage is 2% percent of the first $300, plus
i pereat of aay departed tied pay i enced of S308 s chld bosom, eligible,
cost of coverage will be increased as determined in the next section. The increase in cost
iseffective the first day of the month following eligibility of such child

use and eligible children, The cost of coverage wil be 2% percent ofthe fist $300 of
ee ne, plus a slight additional charge for chil-
dren's coverage that wil vary depending on your age, your wifes age andthe age of your
youngest child. The addtional charge should generally be about one-half of one percent
‘of the amount of retired pay designated

Eligible children only (no spouse). The cost of coverage will vary depending on your age
aad the age of Your younsier old bur should geocraly'be choot B ceovot et hegmoett
of retired pay designated.

Gost reduction - children, When all children cease to be eligible for an annuity, the addi-

‘ional cost for child coverage shall stop. The reduction in cost is effective the frst day of
the month following that in which the last child ceases to be eligible for an annuity.

Natural interest person. Cost of coverage is 10 percent of full retired pay, plus an addi-
‘onal 5 percent of full retired pay for each full five years that your ape Caveeds that of
the natural interest person. The total cost may not exceed 40 percent of retired.pay.

Annuity - spouse andfor eligible children, Full coverage provides an annuity of 55 percent
af retired pay. Reduced coverage provides an annuity of $5 percent of the seduced
amount elected.

‘Annuity -natural interest person, The annuity payable is 55 percent of retired pay semain-
ing after cost of coverage as been subtracted