DESIGNATION, CHANGE, OR REVOCATION OF BENEFICIARY

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP57-00384R000500140103-0
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 3
• Document Creation Date: December 12, 2016
• Document Release Date: January 24, 2002
• Sequence Number: 103
• Content Type: FORM

{
0alta 2806-1
December 1939 IMPORT AI~r a~, r R?~IIftd ~ 99 9u a I p?/p1/31 : CIf-RPP7-0 RRP0500,140103-0
~A~ ~ic'Igd T ona on bar of up irate re Ing in t is form.
(ORIGINAL)
DESIGNATION, CHANGE, OR REVOCATION OF BENEFICIARY
To the United States Civil Service Commission,
Washington, D. C.
h -----------------------------------------------------------------------------------, born on -------------------------------
? ?
(Type or print surname, first, and middle names of employee or annuitant) (Month) (Day) (Year)
an annuitant, or employed as --------------------------------------------------------------- in
(Stenographer, clerk, engineer, etc.) (Department or independent establishment)
-------------------- -------------------------------------- revoking any and all previous designations of beneficiary heretofore made by me,
(City and State)
do now designate the beneficiary or beneficiaries named below, to whom I authorize and direct the United States Civil Service
Commission of Washington, D. C., to pay at my death any money standing to my credit in the Retirement and Disability Fund:
GIVE COMPLETE NAME AND ADDRESS OF EACH BENEFICIARY
STATE SHARE TO BE
PAID TO EACH
Read paragraphs 6, 7, and 8, Instructions
BENEFICIARY
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I hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share of any deceased
beneficiary or beneficiaries who may predecease me shall be distributed equally among the surviving beneficiaries, or entirely
to the survivor. If none survive me, then to my estate.
I hereby specifically reserve the right to remove or change any beneficiary at any time in the manner and form prescribed
by the Civil Service Commission, and without the knowledge or consent of the beneficiary. In the event I withdraw the amount
to my credit in the Retirement and Disability Fund, this designation of beneficiary shall immediately become null and void for
any possible benefits from any future service or otherwise.
(If retired, state Claim No- --------------------- )
If designator cannot write and he signs by mark, the
person assisting him should also sign here and give his
address.
------------ -------------------------------------------------------------
(Written signature of designator in full-DO NOT PRINT)
----------------------------------------------------------------------------
(Number and street)
-------------------------------------
----------------------------------------
(City and State)
WITNESSES
We, the undersigned, having no financial interest in this subject matter, directly or indirectly, hereby certify that we are
personally acquainted with the person subscribing thereto, and that this instrument was subscribed in our presence and in the
presence of each other on the --------------- day of ------------------------------ 194---, and declared to be his (or her) free act and deed.
------------------ ------------------------------------- ----------------------------- --------------------------------------------------
Signature of witness) --------------------------------------------------
(Signature (Number and street) (Cityand State)
---------------------- ---------------------------------- ------------------------------------------
(Signature of witness) (Number and street)
---------------- ----------------
(City and State)
i.,~.~ Da.niono ttI DVI IVLI
DUPLICATE IN ORDER TO TO INSURE RECEIPT OF DUPLICATE COPY FOR PRESERVATION AND FUTURE
Annrnvprl Fnr ERelpagje OZ/U I/ I'? CIA-RDP57-00384R000500140103-0 I
 .s
Ftrsli. 2806-1
December 1930
401 IMPORT~IIa'P: r itea~iiR~'rue nsaand reg0ul tiions3on'b ack of Tupl cat r fn in thiss form. 0 n
(DUPLICATE)
DESIGNATION, CHANGE, OR REVOCATION OF BENEFICIARY
To the United States Civil Service Commission,
Washington, D. C.
- ------------------------------------------------------------------------------------ born on --------
----------------------------------------
(TYPO or print surname, first, and middle names of employee or annuitant) (Month) (Day) (Year)
an annuitant, or employed as --------------------------------------------------------------- in ----------------------------------------------------
(Stenographer, clerk, engineer, etc.) (Department or independent establishment)
---------------------------------------------------------- revoking any and all previous designations of beneficiary heretofore made by me,
(City and State)
do now designate the beneficiary or beneficiaries named below, to whom I authorize and direct the United States Civil Service
Commission of Washington, D. C., to pay at my death any money standing to my credit in the Retirement and Disability Fund:
GIVE COMPLETE NAME AND ADDRESS OF EACH BENEFICIARY
STATE SHARE TO BE
PAID TO EACH
Read paragraphs 6, 7, and 8, Instructions
BENEFICIARY
------------------------------------------------------------------------------------------------------
-------------------------------
--------------------------------
------------------------------------------------------------------------------------------------------
--------------------------------
--------------------------------
------------------------------------------------------------------------------------------------------
--------------------------------
--------------------------------
------------------------------------------------------------------------------------------------------
--------------------------------
--------------------------------
------------------------------------------------------------------------------------------------------
--------------------------------
--------------------------------
I hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share of any deceased
beneficiary or beneficiaries who may predecease me shall be distributed equally among the surviving beneficiaries, or entirely
to the survivor. If none survive me, then to my estate.
I hereby specifically reserve the right to remove or change any beneficiary at any time in the manner and form prescribed
by the Civil Service Commission, and without the knowledge or consent of the beneficiary. In the event I withdraw the amount
to my credit in the Retirement and Disability Fund, this designation of beneficiary shall immediately become null and void for
any possible benefits from any future service or otherwise.
(If retired, state Claim No. ---------------------)
If designator cannot write and he signs by mark, the
person assisting him should also sign here and give his
address.
---------- (-Writt -rft`t -en----signature--------of-----designator---------in----full-----DO----- NOTP---------- RINT)-------------
--------------------------------------------------------------------------------
(City and State)
WITNESSES
We, the undersigned, having no financial interest in this subject matter, directly or indirectly, hereby certify that we are
personally acquainted with the person subscribing thereto, and that this instrument was subscribed in our presence and in the
presence of each other on the --------------- day of -----------------------------, 1.94---, and declared to be his (or her) free act and deed.
Reserved for Receiving Stamp of Civil
Service Commission
(Name of designator)
--------------------------------------------------------------------------------
(Number and street)
----------------------------------------------------------------------- --------
(City and State)
 11, ?1 I U 1i 11Uf4 ;
1. The filinORK00t4orn ~'a ~~A~r~4 b~ 11 MQnp`71 P.WI 90140103-0
2. Form 2806-1, Designation, Change, or Revocation of Beneficiary, is for the purpose of enabling an employee or annuitant
having money to his credit in the Retirement and Disability Funds administered by the United States Civil Service Commission, to
designate the person or persons he desires to receive the money remaining to his credit at death or to change or revoke any designation
he may have previously filed with the Commission. If the person or persons designated as beneficiary by the employee or annuitant do
not survive him, or no designation of beneficiary has been duly filed with the Civil Service Commission by him, payment of the amount
remaining to his credit at death will be paid in a lump sum to the executor or administrator of the estate, or in the absence of such
fiduciary to such person or persons as may appear in the judgment of the Commission to be legally entitled thereto.
3. The designation, change, or revocation of beneficiary must be in writing, typewriting or ink preferred, and signed in the hand-
writing of the designator. A printed or typed signature should not be used. If designator cannot write and his signature is by :mark,
it should be so indicated at the left thereof with name and address of person assisting him. The designation must be signed in the
presence of two witnesses (not beneficiaries), and must show the date of execution. All spaces in the designation of beneficiary form
must be completed. The duplicate copy of prior designation should accompany the change of beneficiary, if it is available.
4. The designation, change, or revocation of a beneficiary must be received by the Civil Service Commission prior to the death
of the employee or annuitant to have full force and effect. A delay of even a day in the completion and the mailing of the designation
may result in its invalidation; hence, the necessity for prompt mailing direct to the Civil Service Commission, Washington, D. C.
5. A designator who changes his or her name subsequent to the filing of a beneficiary form with the Commission should immediately
file another such form, using his or her present name at the top of the form, followed, in parentheses by the name under which the
former designation was submitted; e. g "Mary Elizabeth Jones (formerly Mary Elizabeth Smith)." It is not necessary to file a new
designation where the address of the beneficiary or the designator has been changed or there has been a change in the position held
by the designator.
6. If a beneficiary is a minor, his date of birth should be given. If a guardian or trustee is named for a minor, the designator
should state whether qualification by a court of competent jurisdiction is intended. The Commission is not a probate court and
cannot follow payments made to a natural guardian, trustee, etc.
7. SAMPLES OF DESIGNATIONS.
NAME OF BENEFICIARY:
Samuel Lawrence Jones (not S. L. Jones).
Sarah Mitchell Jones (not Mrs. Samuel L. Jones).
John Henry Smith and Mary Jones Smith (not Mr. and Mrs. J. H. Smith).
CONTINGENT BENEFICIARY:
Mary Ann Smith Wife. All.
If my wife predecease me, to-
Margaret A. Smith (born August 14, 1932). Daughter. One-half.
James R. Smith (born October 12, 1934). Son. One-half.
WHERE TRUSTEE OR GUARDIAN Is NAMED:
John Henry Smith (brother) Trustee to be (not to be) appointed by the court for benefit of-
Lucille Smith (born June 1, 1936). Daughter. One-half.
Henry A. Smith (born August 1, 1938). Son. One-half.
If persons named be of legal age at my death, payment to be made to them direct.
REVOCATION ONLY:
To my estate (see paragraph 8, below).
8. Revocation of a prior designation may be effected without the naming of a new beneficiary by making out a new Form 2806-1
and inserting in the space provided for name of beneficiary, the words, "To my estate."
9. The "Designation of Beneficiary" form is not intended as a will, and miscellaneous provisions, such as payment of just debts,
payment to the beneficiary on the monthly installment plan, payment to specified persons in event certain beneficiary survives desig-
nator and dies before collecting amount due, etc., should not be incorporated therein and will not be recognized.
10. Corrections or erasures in a "Designation of Beneficiary" form may, in case of a contest after death, result in nullification of
the designation; hence, a designation free of erasures or alterations should be filed.
11. Where more than one person is designated as beneficiary, each beneficiary will receive an equal share, unless the share or
percentage to be paid to each beneficiary is specified, in which case each beneficiary will receive the portion indicated.
12. Where a designation of beneficiary has been previously filed with the Commission, and Form 2806-1 is used in order to revoke,
change, or to add beneficiaries, the beneficiaries originally designated who are to continue as beneficiaries must be again designated on
the new form; otherwise they will be excluded as beneficiaries.
REGULATIONS
1. The designation, change, or revocation of beneficiary shall be in writing on the prescribed Form 2806--1, signed and acknowl-
edged in the presence of two witnesses personally acquainted with the designator, neither of whom shall be named as beneficiary, and
must be received in the Civil Service Commission prior to the death of the designator.
2. Any person, firm, corporation, or legal entity may be named as beneficiary.
3. A revocation or change of beneficiary may be made at any time and without the knowledge or consent of the previous bene-
ficiary. Alterations or insertions restricting the right to change or revoke a designation cannot be given any force or effect. No change
or revocation of beneficiary in a last will or testament, or in any other document not witnessed and filed as required by these regula-
tions shall have any force or effect.
4. Where a writing, other than Form 2806-1, signed by the designator and duly witnessed by two persons, is received in the Com-
mission prior to the death of the designator, in which a clear and unambiguous revocation or change of designation of beneficiary is
made in substantially the same manner as that provided on Form 2806-1, and the designator dies without confirming the change or
revocation by the execution of the prescribed Form 2806-1, the revocation or change shall be given the same effect as if executed on
Form 2806-1: Provided, however, That the Civil Service Commission shall, upon receipt of said writing, forward a blank Form 2806-1
to the designator at the last address furnished by him for confirmation on that form of the previous writing which shall become null
and void if (1) death occurs 60 days after the filing of the first form, and (2) if no confirmation is received on said Form 2806--1 within
said period.
5. A designation of beneficiary or a change or revocation of beneficiary may be made only by an employee subject to the act
whose name is borne on the rolls of the department or independent establishment at the time of execution thereof, or by an annuitant,
actual or potential.
6. All regulations pertaining to designation, change, or revocation of beneficiary heretofore promulgated and inconsistent with
these regulations are hereby revoked. Designations heretofore properly executed and filed with the Commission prior to the approval
of these regulations will be given full force and effect.
7. These regulations apply to designations, changes, or revocations of beneficiary by employees or annuitants subject to the acts
of May 29, 19.~V ~JQ{/ '~Q`p e 2 ~v(E'} nd after January 1, 1940.
U. 8, GOVERNMENT ING OFFICE ] $e~e~0~~ 10 ~~Nt/]]]' V11L (~~i/p+~/m_RVICE COMMISSION.