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

Document Type: 
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
Sequence Number: 
Case Number: 
F-2007-00327
Publication Date: 
May 21, 1970
File: 
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PDF icon DOC_0001411694.pdf79.03 KB
Body: 
~APPROVED FOR RELEASE DATE: 10-Nov-2008 1 611 "! dy '~rr-- s`~ n :?i'i/?wl wG.l S "i JLLY IsI bd 02903 Pod A.-? 9 LNYEEt~s64~ DMA ( 1. NAME (LAST) (FIRST) (MIDDLE INITIAL) JS'.r7 m CLranciD NOTE OF CV AGE IN WkALT97 B a LF(TS E6`7 tOLUJI AT ?,9N 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. 9 osff C.? E FAUNA TBCs4 ^ 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): -gym & Disabi ") l lt~tei' t-~7~.,0 21 VTL,Eln Fl, t o a5 Da Co (SEE PART D ON THE BACK OF THIS FORM FOR MORE INFORMATION) , j 1:.--SWsMES c&v 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 (bl61 (b131