NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411694
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: May 21, 1970

~APPROVED FOR
RELEASE DATE:
10-Nov-2008 1
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NOTE OF CV AGE IN WkALT97 B a LF(TS E6`7 tOLUJI AT
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ONLY THE ITEM WHICH IS CHECKED BELOW AFFECTS YOUR ENROLLMENT. READ THAT ITEM CA ?tE s'TLILLY AND FOLLOW ANY PESiIIIca-iT
INSTRUCTIONS. REEF THIS FORM UNLESS YOUR ENROLLMENT IS TERMINATED AND YOU APPLY FOR CONIVE SIONN.
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^ YOUR ENROLLMENT TERMINATES ON THE DATE IN PART A, ITEM 7, ABOVE.
IMPORTANT NOTICE.-You have the right to convert to an individual contract with the carrier of your plan. See Port B.-Termination on
the back of this form for information about your extension of coverage and conversion. If you want to convert, fill in the box on the back
of this form and send it to your plan within the time limit specified.
1-E YOUR ENROLLMENT SHOWN IN PART A, ITEM 6, ABOVE HAS BEEN TERMINATED BECAUSE OF YOUR ENROLLMENT IN ANOTHER PLAN.
YOUR ENROLLMENT CONTINUES BUT IS TRANSFERRED TO
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM):
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(SEE PART D ON THE BACK OF THIS FORM FOR MORE
INFORMATION)
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YOUR ENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON
THE DATE IN PART A, ITEiv1 7, ABOVE.
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM) L ! II
SHOWN IN PART K BELOW HAS ACCEPTED TRANSFER OF
YOUR ENROLLMENT AND WILL CONTINUE IT.
2. DATE OF BIRTH
O 7 22
YOUR ENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON
THE DATE IN PART A, ITEM 7, ABOVE.
Peed H.- CHANGE 2E' 6 AME OF ENROLLEE
ADDRESS (INCLUDING ZIP CODE) IF DIFFERENT FROM PART A, ITEM 4, ABOVE
6'? sr f.- CE-0.A,S4GE H4 ENROLLMENT SURVIVOR ANHWAHIT
YOUR ENROLLMENT HAS BEEN CHANGED FROM FAMILY COVERAGE TO SELF ONLY. YOUR PLAN WILL
SEND YOU A NEW IDENTIFICATION CARD.
YOUR NEW ENROLLMENT
CODE NUMBER
(NOTE: THIS ITEM TO BE COMPLETED BY RETIREMENT SYSTEMS ONLY)
^ MALE
^ FEMALE
central Intelligence Ageracy
NAME OF AGENCY VVsa.Sh~44 E~2~4ti',LUO7UG ?I. CODs,j(;j
Original -To Enrollee
Standard Form No. 2610
April 1969
FPM Supplement 690.1
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