Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
Sequence Number: 
Case Number: 
Publication Date: 
April 6, 1970
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APPROVED FOR RELEASE DATE: 10-Nov-2008 APPLICATION-FOR RETIREMENT v. v ~ u 1 I- 1 1 1 J 1. 1 1. IVI To avoid delay-I. Read information carefully; Complete app ication in full; Typewrite or print in i;,R A. PERSONAL INFORMATION I. NAME (Last) MR (1`77 - (Middle) 2. DATE OF BIRTH CORRES: 64 Veldt Street CHECKS: rrS M coarrompm, 5. (A) ARE YOU MARRIED? ^YES NO HER (OR HIS) BIRTH DATE (Month) (Day) L (Year) WIFE'S OR HUSBAND'S NAME (First) (Middle) D DISABILITY INFORMATION 1. OF ASSIGNMENT 2 SERVICE DESIGNATION 3. LOCATION OF EMPLOYMENT (City and State) Do, C"o F LAST POSITION 5.DATE O NAL SEPARATION (Month) (Day) (Year) 6. APPROXIMATE NUMBER OF YEARS OFol CIVILIANS $ 1 + RVIC ~ ft , f E s . E U HAVE FEDERAL EMPLOYEES GROUP LIFE INSURANCE? 8. ARE YOU ENROLLED IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS: YES ^ NO PROGRAM? YES ^ NO C. MI LITARY SERVICE 1. COMPLETE THE SCHEDULE BELOW IF YOU HAVE PERFORMED ACTIVE DUTY THAT TERMINATED UNDER HONORABLE CONDITIONS IN ANY OF THE FOLLOWING SERV- ICES: ((A ARMY, NAVY, MARINE CORPS, AIR FORCE, OR COAST GUARD OF THE UNITED STATES; OR (B) REGULAR CORPS OR RESERVE CORPS OF THE PUBLIC HEALTH SERVIC~ AFTER JUNE 30, 1960; OR (C) AS A COMMISSIONED OFFICER OF THE COAST AND GEODETIC SURVEY AFT YOUR DISCHARGE CERTIFICATE. ER JUNE 30, 1961. IFAVAILABLE, ATTACH A COPY OF BRANCH OF SERVICE SERIAL NUMBER DATE OF ENTRANCE ON ACTIVE DUTY DATE OF SEPARATION FROM ACTIVE DUTY .. LAST GRADE OR RANK ORGANIZATION AT DISCHARGE (Div., Regt., Co., etc.) iJ. .. AZMy 31 182993 A? C*t 42 5 A 46 TS 2. (A) ARE YOU A MILITARY RE- SERVIST (EITHER ACTIVE 2. (B) ARE YOU IN RECEIPT OF OR HAVE YOU EVER APPLIED FOR MILITARY RETIRED PAY? (RETIRED PAY DOES NOT IN- 2. (C) IF "YES," WERE YOU RETIRED FROM A RESERVE COMPO- NENT UN OR INACTIVE)? CLUDE V.A. PENSION OR COMPENSATION.) DER CHAPTER 67, TITLE 10, U.S.C. (FORMERLY TITLE 111, PUBLIC LAW 80-S10)? ^ YES LJ NO ^ YES M NO ^YES ^ NO E. OTHER CLAIM INFORMATION 2. BRIEFLY DESCRIBE YOUR DISABILITIES. STATE WHEN INCURRED, AND HOW THEY INTERFERE WITH PERFORMANCE OF THE DUTIES OF YOUR POSITION. (ATTACH ADDITIONAL COMMENTS ON PLAIN SHEET OF PAPER IF NECESSARY.) 1. (A) HAVE YOU EVER RECEIVED OR MADE APPLICATION FOR COMPENSATION UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT' Will 4%"ty RE YES 2. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIVIL SERVICE RETIREMENT SYSTEM, INCLUDING APPLICATION FOR RETIREMENT, REFUND, DEPOSIT OR REDEPOSIT, OR VOLUNTARY CONTRIBUTIONS? ^YES N !3. (A) HAVE YOU PREVIOUSLY FILED ANY APPLICATION UNDER THE CIARETIRE- MENT & DISABILITY SYSTEM, INCLUDING APPLICATION FOR RETIREMENT, REFUND, PURCHASE OF SERVICE CREDIT, OR VOLUNTARY CONTRIBUTIONS? y E=:1 YES ^ NO I, (B) IF "YES," STATE THE NUMBER OF YOUR COMPENSATION CLAIM.AND THE PERIOD FOR WHICH YOU RECEIVED COMPENSATION__ CLAIM NUMBER FROM (Month) (Da ) (Year) ' .70 (M y onth) (Day) (Y) ear 2. (B) IF "YES," INDICATE THE TYPES) OF APPLICATION AND GIVE THE CLAIM NUMBER(S) IF KNOWN ^`RETIREMENT ^ DEPOSIT OR REDEPOSIT REFUND VOLUNTARY ^ CONTRIBUTIONS 3. (B) IF"YES," INDICATE THE TYPE(S) OF APPLICATION: RETIREMENT PURCHASE OF SERVICE CREDIT ^ REFUND ^ VOLUNTARY CONTRIBUTIONS 4. (B) IF "YES," GIVE THE NAME OF THE OTHER RETIREMENT SYSTEM Civil Service System 4. (A) HAVE YOU EVER BEEN EMPLOYED UNDER ANOTHER RETIREMENT SYSTEM FOR FEDERAL OR DISTRICT OF COUMBIA EMPLOYEES?IR ^ X YES NO SE/ET 7____"" DATE OF MARRIAGE (Month) (Day) (Year) B. CIVILIAN SERVICE INDICATE, BY SIGNING YOUR INITIALS APPROPRIATE 'BOX BELOW, THE TYPE OF ANNUITY YWNT TO RECEIVE. READ THE EXPLANATIONS AND CONSIDER THE MATTER CAREFULLY. NO ANGE WILL BE PERMITTED AFTER AN ANNUITY HAS BEEN ANTED. = IF YOU WANT, AN ANNUITY WITH A SUR- VIVOR BENEFIT, BE SURE TO GIVE THE OTHER INFORMATION CALLED FOR. ri, ANNUITY WITH SURVIVOR BENEFIT TO WIDOW OR WIDOWER SPECIFY THE PORTION OF YOUR ANNUITY YOU WANT. USED AS THE BASE FOR YOUR WIDOW'S (OR WIDOWER'S) SURVIVOR ANNUITY. 11 you want all your annuity used as the base for the survivor benefit, write the word "all" In the~box below. If you want only part of your annuity used as the base for the survivor benefit, write the yearly amount of your annuity you want used. THE SURVIVOR'S ANNUITY WILL BE 55% OF ALL OR WHAT- EVER PORTION OF YOUR ANNUITY YOU SPECIFY AS THE BASE FOR HER (OR HIS) BENEFIT. she (or he). dies. or remarries.. INITIALI cc ANNUITY WITHOUT SURVIVOR BENEFIT (I do not desire my wife (or husband) to receive..a survivor annuity benefit after my death.) ? If you are married, you will receive this type of annuity unless you choose the annuity in Fl 2. -40-0 The annuity payable to you during your lifetime will be reduced the survivor benefit, plus 10% of any "amount over $3,600 so used. ? If you retire for total disability before age 60 and get a guar- anteed minimum disability annuity, you may use all or any part of your "earned annuity as the base for the survivor benefit: You cannot use anyex'tra annuity which may be payable to make up the guaranteed minimum annuity. ? If your wife (or husband) should die before you, no change in type of annuity will be permitted, your annuity will not be in- creased, nor may you name any other person as survivor. --? If you choose this type, :your.wife:(or husband) cannot be paid a survivor annuity after your death. ? This type provides annuity payments, to-you only. G. TYPES OF ANNUITY: UNMARRIED APPLICANTS ONLY (Including Widowed and Divorced) ANNUITY WITHOUT SURVIVOR BENEFIT ANNUITY WITH SURVIVOR BENEFIT TO NAMED PERSON HAVING AN INSURABLE INTEREST SPECIFY THE NAME, RELATIONSHIP AND DATE OF BIRTH OF THE PERSON YOU WISH TO RECEIVE THE SURVIVOR ANNUITY SEE UNMARRIED EMPLOYEES UNDER INFORMATION REGARDING SURVIVOR ANNUITIES ON THE ATTACHED INFORMATION SHEET FOR EXPLANATION OF REDUC- TION IN YOUR ANNUITY. ? If you are not married, .you will receive this type of annuity unless you choose the annuity in G. 1: ? This type provides annuity payments to you only. ? This type, is available to all retiring unmarried employees who are in good health. ? It provides 'a reduced annuity to you and a survivor annuity to the person named as having an insurable interest. ? The survivor's annuity will begin upon your death and end when The survivor's annuity, will be 55% .of:the reduced annuity you receive. If you choose this type, you will have to undergo a medical examination which will be arranged by the Director of Personnel ? If the person named as having: an insurable interest should die before you, no change in type of ahnuity.wi l be permitted, your, annuity will not be increased, nor may you name any other person as survivor. oo violation application WARNING~Any willful misrepresentation ll relative statement isl this of the e law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both (18 U.S.C. 1001). I hereby certify that all statements made in this application are, true to the best of my knowledge and belief. 6 Apr 1970: /0/.John C. Caranci. (DATE) (SIGNATURE OF APPLICANTI 1. FOR OFFICE OF PERSONNEL USE ONLY [INITIALS