Document Type: 
Document Number (FOIA) /ESDN (CREST): 
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Document Creation Date: 
June 22, 2015
Document Release Date: 
March 20, 2008
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Case Number: 
Publication Date: 
June 11, 1971
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STANDARD FORM 56 JANUARY 1970 -AGENCY CERTbfCATION= OF 4'( INSURANCE STATUS -' (b) (3 ) UTVI COMMISSION (b) (6) l E d E l F l 87070-1 56-1 109 FPM SUPPLEMENT era mp e oyees Group L1 e insurance Program 1. NAME (Last) (First) (Middle) -).,DATE OF BIRTH (Month, oay, Year) 2(b). SOCIAL SECURITY ACCOUNT NUMBER COLLINS,, Charles ,P. Z Dec 19.16 3. CHECK THE REASON. FOR TERMINATING INSURANCE (a) [8 Separated (includes resignations) (b) Retired NOTE: If the reason checked is "b; Retired".your group life insurance (but? (c) E Died as an employee not accidental death and dismemberment benefits) will continue during retire- (d) Died as a reemployed annuitant:- ment if you meet the conditions described in "Notice to Retiring Employee" below. (e) End of 12 months non-pay status (f) Other (specify) 4. CHECK APPROPRIATE BOX CONCERNING SF 54, DESIGNATION OF BENEFICIARY CURRENT A CURRENT SF 54 IS A CURRENT SF 54 IS ON FILE IN (?) (b). X NOT ON FILE WITH THIS (c). THE EMPLOYEE'S OFFICIAL PERSONNEL SF 54 ATTACHED AGENCY FOLDER (OR EQUIVALENT) NOTE: IF EMPLOYEE (A) DIED OR (B) IS RETIRING OR RECEIVING FEDERAL EMPLOYEES' COMPENSATION UNDER CONDITIONS ENTITLING HIM TO RETAIN HIS LIFE INSURANCE, ATTACH CURRENT SF 54, IF ANY, TO ORIGINAL SF 56 AND CHECK BOX 4 (a) ON ORIGINAL AND ALL COPIES OF SF 56; IF NO CURRENT SF 54 IS ON FILE, CHECK BOX 4 (b).-1N`-ALL OTHER CASES, SHOW WHETHER OR NOT CURRENT SF 54 IS ON FILE BY CHECKING BOX 4 (b) OR (c). A CURRENT SF 54 IS ONE THAT HAS NOT BEEN CANCELED BY EMPLOYEE OR AUTOMATICALLY BY TRANSFER OR PRIOR TERMINATION OF INSURANCE. 5. DATE OF EVENT CHECKED IN ITEM 3 6. ANNUAL BASIC PAY RATE (NOT AMOUNT OF INSUR- 7. DID EMPLOYEE HAVE OPTIONAL INSURANCE ON DATE 8. DATE Of NOTICE OF CONVERSION (MONTH, DAY, YEAR) ANCE) ON DATE IN ITEM S. CONVERT DAILY, HOURLY, IN ITEM 5? NO fl YES ) PRIVILEGE (SF 55) TO EMPLOYEE PIECEWORK, ETC. RATE TO ANNUAL RATE. IF YES, GIVE RECEIPT, DATE Of ELECTION OF OPTIONAL (MONTH, DAY, YEAR) 28 May 1971 $ L9 PER ANNUM S~JA INSURANCE ( F'br Tq'6 8 9. I CERTIFY THAT THE ABOVE INFORMATION HAS BEEN OBTAINED FROM, AND CORRECTLY REFLECTS, OFFICIAL RECORDS AND THAT THE EMPLOYEE NAMED WAS COVERED BY FEDERAL EMPLOYEES GROUP LIFE INSURANCE ON THE DATE SHOWN IN ITEM 5. Personal signat ure of authorized agency Name and address of agency, including zip code Central Intelligence Agency Typednameo - Washi t D C 205 ng on, . . 05 Title Phone number, including area code Date ` Officer, Alternate RR I dYI 1971 INSTRUCTIONS TO EMPLOYING AGENCY COMPLETION OF CERTIFICATION 1. This Certification must be completed in triplicate whenever an employee's insurance terminates for: a. Death. b. Retirement on an immediate annuity with 12 or more years' creditable service, of which at least 5 years are civilian service, or on account of disability. (An immediate annuity is one which begins to accrue not later than 1 month after the date the insurance would normally cease.) In a disability retirement case, do not complete SF 56 until a finding of disability has been officially made and the employee's separation is in order. c. Completion of 12 months in a non-pay status or separation, and the employee is receiving benefits under the Federal Employees' Compensation law, and held unable to return to duty. ._.Any.other._reason.,_ifJhe_employee-.desires-.Lo_.converthis-life insurance, except under the.,following..circurnstances: (1) Employee waived or declined on SF 176 (or SF 176-T); (2) If it is known that; within 3 calendar days after the date the insurance terminated, the employee will return to Government service in-theiirne or'an'other'posttron in which he will be eligible to reacquire Federal Employees Group Life Insurance; (3) More than 75 days have elapsed from the date insurance terminated unless specific request is made therefor by the Civil Service Commission or the' Office of Federal Employees' Group Life Insurance. 2. If insurance terminated on account of death, indicate in item 3(a) whether the employee had filed an Application for Retirement (~~~180~)w(tYi the Civic-Servwe mission. " ?_ - ``- '"`"- ""` 3. In item 8, give date of Notice of Conversion Privilege (SF 55), except that if this form (SF 56) is issued in lieu of SF 55, give current date. In case of death, leave this item blank. 4. It is important whenever a duplicate SF 56 is issued to replace one which has been lost, that it be clearly marked "DUPLICATE". DISPOSITION OF CERTIFICATION 1. Death of employee a. Send duplicate of SF 56 immediately to the Office of Federal Employees' Group Life Insurance. b. Keep the original (preferably in the Official Personnel Folder or its equivalent) for attachment to a claim for death benefits T ,(FoIrn;FE-6) -when-received c if no claim is received send original SF 56, upon request, to the Office of Federal Employees' Group Life Insurance. If the deceased employee has a current ,Designation of Beneficiary i(SF 54) on file, the SF 54 must be "attached to the 'original tSF 56"wrhenit is sent to the Office of Federal Employees' Group Life Insurance. [jXbq cans o,,c+2u~Retrremeat rof employee- applying a ie emplo'yeeis "loran `immediate annuity with 12 .or. more. years; creditable service, (of which at least 5 years are civilian service) or for disability, attach the original SF 56 and current Designation of Beneficiary (SF 54), if .'t .~: ,an t. o tJie' Application for Retirement and give di u of SF 56 'to the employee, ee, NOTE: In a disability retirement case where the retirement application has already been sent to the Civil Service Commission, attach'the original SF-56 YiVW D r