HEALTH BENEFITS REGISTRATION FORM - MILLS, MONTRELL EUGENE

• Document Type: FOIA
• Keywords: MILLS MONTRELL E
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001308865
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Release Date: February 19, 2008
• Case Number: F-2005-00558
• Publication Date: July 10, 1960

 Standard  Form No. 2809 1'IEALTH BENEFITS REGISTRATION FARM  ~i~G~~ /,. CARRIER'S CONTROL NO. CHAPTER I-5 E'. P.M. FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 19s9   v/ .~ 6 GAO 5000 (Read Instructions on back of last page.   Use only typewriter or ballpoint pen.) I . NAME        (LAST)                    (FIRST)                   (MIDDLE INITIAL) 2.  DATE OF BIRTH 3.  Are you now married? T~~, ?f _ MiZ1s              Montrell                ~~ (Use numbers) ~ PART A M;NTH     DAY            YEAR ~ ry TJ YES ~ i       . T+ +?       a S?i No  ^Q ALL WHO REGISTER 4. YOUR MAILING ADDRESS   (NUMBER AND STREET?                       (CITY AND ZONE NUMBER)   (STATE) 5. SEX ~0 MUST FILL N( THIS 2623  West IJewton Circle            Irving          Texas MALE FEMALE ^~ 6. Are you covered by, or is any family member listed below cov- 7. Place an "X",in proper box to show your annual basic salary PART. Bred by or enrolling in, a plop under the Federal Employees range. Health Benefits Act of 1959 (through the enrollment of another United States or District of Columbia Government employee or UNDER 34,000 ^Ol   36,000 TO 39,999 ^^3 annuitant)?                     YES ~       NO ? 34,000?TO 35,999  ^~   310,000 OR OVER  ~Q PART B 1. I sled to enroll in a health beneAri plan as shown below.   I authorize deductions ro be mode from my salary, compensation, or annuity Flll IN THIS to cover my share of the cost of the enrollment.   (Copy the information requested below from inside cover of brochure of the plan you select.) PART IF YOU wlsN To EN? NAME OF PLAN                                                                      OPTION (HIGH OR LOW)       ENROLLMEtT CODE NUMBER ROLL IN A 1ss.Ciatian Be~nefYt Plan                   High           !~  (  2   2 ' HEALiN BENEFITS ~? 2. In space below list all eligible family memben without exception: List your wife or husband first, then your unmarried children under age 19, including legally adopted children, and stepchildren and illegitimate children who live with you in a regular parent-child relation- ship.   Include also any unmarried child over 19 who became disabled before age 19 and who, because of the disability, is incapable of self-support.   (ANadr o doctor's certificate for a dfsobfed child age 19 or over.) M enrollment if for sslF only NAMES OF FAMILY MEMBERS DATE OF BIRTH yam) (Month ~ NAMES OF FAMILY MEMBERS DATE OF BIRTH (M Da ar) m Y answer  Item  1. y y, on , e If enrollment is  for  self  and Wife or H b d  M g i 2 6 family, else us an ar  Qr e 2 2 answer  item  $ and item 3 if Q 7 it applies. Thetas  s  Mills o Robert t3 6                 ? ~ THIS PART MUST ~ 10 ALSO BE FILLED IN IF YOU 3. If you are a female (employee or annuitant)-does The family listed above include a husband who is incapable of self?   YES (RANGE YOUR support by reason of mental or physical disability which can be expected to.continue for more than one year?   (If answer ENROLLMENT, is "Yes," attach a doctor's certificate.)                                                                              NO PART C PLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3. FILL IN THIS 1. I elect not to enroll in any plan 3. The reason for my election is (Place an "X" in proper box): PART IF YOU under the Health Benefits Act. ^ (a}  I am covered by a plan under the.Health Benefits Act through the enroll-   ~^j WISH NOT TO ment of my husband, wife, or parent. ENROLL OR IF YOU WISH TO 2. I elect to cancel my present enroll- b   tam covered b  a health insurance  Ian which is not under the Health          4 ()          Y               P                                                   ~~ CANCEL YOUR ENROLLMENT. ment under the Health Benefits Act.   ^ Benefits Act. (c) Any other reason.                                                           ~^3 PART D I elect to change~my enrollment as shown by the enrollment number and other information in Part B. FILL IN TNIS 1 ? Enrollment code number of present plan. 2. Number of event which permits change. 3. Dare of event which permits change. PART IF YOU (See fabb on back of duplicate kr proper number.) WISH TO MONTH DAY YEAR [RANGE YOUR E!JROLIMENT. PART E ALL WHD WARNING.-Any intentional false statement in _ ~ this application or willful misrepresentation relative REGISTER P thereto is a violation  of the law punishable by o MUST Flll L^ 15 J 1960 fine of not more than ;10,000 or imprisonment of IN THIS PART une not more than 5 years, or both.  (18 U.S.C. 1001.) . (YOUR SIG  ATURE-D   O  PRINT)   fDATEI 1. NAME AND ADDRESS OF EMPLOYING OFFICE 2.  DATE RECEIVED IN               3.  EFFECTIVE DATE OF EMPLO ING OFFlC             ELECTION PART F ~ ~ ~ ~d "' TO RE ~j p a COMPLETED BY - BENEFITS OFFICER 4. PAYROLL OFfKE h10.              S. PAYROLL ACTION HEALTH nALS AND ATE) AGENCY. ~O {SIGNATURE OF AUTHORIZED AGENCY OFFIiaAU REMARKS FOR USE ONLY APPROVED  FOR  RELEASE BY ANNUITANTS AND AGENCY. DATE:  NOV  2007 ,