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

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411857
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 6
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: April 1, 1970

Standard Form No. 2810
U.S. Civil Service Commission
FPM Supplement 890.1
November 1965
Part A.-IDENTIFYING DATA
(bl61
(b131
ONLY THE ITEM WHICH IS CHECKED BELOW AFFECTS YOUR ENROLLMENT. READ THAT ITEM CAREFULLY AND FOLLOW ANY PERTINENT
INSTRUCTIONS. KEEP THIS FORM UNLESS YOUR ENROLLMENT IS TERMINATED AND YOU APPLY FOR CONVERSION.
Part B.-TERMINATION
^ YOUR ENROLLMENT TERMINATES ON THE DATE IN PART A, ITEM 7, ABOVE.
APPROVED FOR RELEASE DATE:
10-Nov-2008
^ 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):
3. CARRIER CONTROL NO.
0 8s"
Part E.-TRANSFER IN
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM) SHOWN I_
!
IN PART K BELOW HAS ACCEPTED TRANSFER OF YOUR EN-
ROLLMENT AND WILL CONTINUE IT.
YOUR ENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON
^ THE DATE IN PART A, ITEM 7, ABOVE.
NOTICE OF. CHANGE IN HEALTH BENEFITS ENROLLMENT
64 Eddy Stx
Cierdale, Rbade Island OZ911
Part G.-REINSTATEMENT
YOUR ENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON ^
THE DATE IN PART A, ITEM 7, ABOVE.
Part H.-CHANGE IN NAME OF ENROLLEE
THE NAME IN WHICH THIS ENROLLMENT IS CARRIED HAS BEEN CHANGED TO:
Part I.-CHANGE IN ENROLLMENT-SURVIVOR ANNUITANT
YOUR NEW ENROLLMENT
CODE NUMBER
(NOTE: THIS ITEM TO BE COMPLETED BY RETIREMENT SYSTEMS ONLY)
Part J.-REMARKS
Employee ui. .
Part K.-DATE OF NOTICE
Chief,
Quadruplicate-To Employing Office
 PURPOSE OF FORM
This form covers health benefits actions except enrollments, changes of coverage within a plan, and cancellations which are processed on Health
Benefits -Registration Form .(SF.2809). When. an .action. requ.ires".a..change.. in health benefits- -enrollment, prepare SF 2810 as soon as the- effective.. date is
known and give the appropriate copies to the enrollee and payroll office immediately., Preparation and distribution of copies should not be delayed pending
SF 50 action, in the case of transfers to another payroll office.
To be eligible to convert to a nongroup contract, enrollee must furnish his copy of this notice to his Plan not later than 31 days after the date shown
in Part A, item 7, or 15 days after the date shown in Part K, whichever gives 'him more time. Therefore, make this form available to the enrollee as soon
as possible.
COMPLETION OF FORM
PART A-IDENTIFYING DATA
1. For Items- 1, 2-3, and 6, transcribe from the last SF 2809 or SF 2810,
whichever is the most, recent.
2. Item 4, use most recent known address.
3. Item 5, use payroll office number of office authorized to process with-
holdings,
4. Item 7, date as follows for action reported in,
B. TERMINATION-Last day of pay period in which separation (or
other action terminating enrollment) occurs except, when coverage
terminates because of completion of 365 days in nonpay status,
C. CHANGE IN PLAN-Last day of pay period preceding effective
date of election to change plans.
D. TRANSFER OUT-Actual date.
E. TRANSFER 'IN-Actual date.
F. SUSPENSION-Actual date.
C. REINSTATEMENT-Actual date.
H. CHANGE IN NAME OF ENROLLEE-Actual date.
1. CHANGE IN ENROLLMENT-SURVIVOR ANNUITANT- Effective
date of sole survivor's annuity.
PART B-TERMINATION
These most frequently occurring actions terminate enrollment with
enrollee eligible to convert to individual contract;
Separated
`Furloughed by reason of reduction in force
Retired-not. eligible to continue enrollment
Died-no survivor eligible to continue enrollment
Termination of title to annuity or compensation
Changed to excluded position or category
365 days nonpoy status completed '
Entered military duty not limited to 30 day's or less
Employee organization gives notice to terminate employee's enroll-
PART D-TRANSFER OUT
SF 2810 for transfer between employing offices serviced by the
some payroll office number)
Retired-Transfer to a retirement system-employee appears eligible
to continue enrollment as an annuitant
Death-Transfer to retirement system-survivor appears eligible to
PART E-TRANSFER IN
Gaining office use this box to report transfer actions, such as:
Acceptance of transfer from another agency or payroll office number
Retired-Acceptance of transfer by retirement system because em-
ployee is eligible to continue enrollment as an annuitant
Death-Acceptance of transfer by retirement system because survivor
is eligible` to continue enrollment as a survivor annuitant
Transfer accepted by Bureau of Employees' Compensation.
NOTE: Retirement systems (including BEG) accepting transfer in,' show
also in "Remarks" whether enrollment is for an "EMPLOYEE
ANNUITANT" or "SURVIVOR ANNUITANT.-
.PART ` F-SUSPENSION and PART G-REINSTATEMENT
State in "Remarks" reason for any 'action not- applicable to active
military duty -such -as "Reinstatement of, erroneous separation."
PART H-CHANGE IN NAME OF ENROLLEE
Use this box only for .reporting changes in name where change of
coverage within a plan by SF 2809 is-not involved. Show date of
birth. only where enrollment is changed from employee's or anhulitant's
name to name of survivor annuitant.
PART I-CHANGE IN ENROLLMENT-SURVIVOR ANNUITANT
Only agencies 'administering retirement systems will make this deter-
mi1notiort on the basis of documentary evidence that there is only one
-.PARTJ-REMARKS.---,- _
Use this box to bring to the attention of the employee, annuitant, or
carrier any pertinent information to clarify or support the action being
taken.
ORIGINAL-De tee: for mail) to employee, onnuitani, or survivor at eorliest pas?ibie date. In case a termination 'SF 281-0 mvsi be issued more than 75
days after the effective date of termination, destroy the ariginai copy.
DUPLICATE and TRIPLICATE-Send to opproariote payroll office.
tiUA3+".UPL(CATE-Fil_ in Oifi:ial ne.rsores, Fr i_' (r ., en_' c,e,") =x r1' r- uses death or, retirement reported as "Transfer Out" is eer?.er ni
en (veiny Rrreeu of Emw'c ou. c:. !n n r he triplicate copy of each tiec,tth Benefits Reg :...aior rerc. (Sr 2e':0) ..- n, t
_ m. 'r.e er-plcyee including ore Meaicc,' Certificat . , . site :hec ;hc ete_ r i c'uadrupli cote SF 2810 -to app-.opnhate pe. eoll office, for irans~n
agency or office administering retirement or ccmiksnsu?ian system.
 U.S. Civil Service
Commission
ONLY THE ITEM WHICH 15 CHECKED BELOW AFFECTS YOUR ENROLLMENT. READ THAT ITEM CAREFULLY AND FOLLOW ANY PERTINENT
INSTRUCTIONS. KEEP THIS FORM UNLESS YOUR ENROLLMENT IS TERMINATED AND YOU APPLY FOR CONVERSION.
Part B.-TERMINATION
^ 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):
YOUR ENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON
THE DATE IN PART A, ITEM 7, ABOVE.
THE NAME IN WHICH THIS ENROLLMENT IS CARRIED HAS BEEN CHANGED TO: ^
NAME
DATE OF BIRTH
SEX
^
MALE
^ FEMALE
ADDRESS (INCLI.)DING ZIP CODE) IF DIFFERENT FROM PART A, ITEM 4, ABOVE
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
IMS 0ii'FICjM
TA ? enw .
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
CJ
NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM) El
SHOWN IN PART K BELOW HAS ACCEPTED TRANSFER OF
YOUR ENROLLMENT AND WILL CONTINUE IT.
YOUR ENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON D
THE DATE IN PART A, ITEM 7, ABOVE.
AL DATE
Central Intelligence A88ar9
Washington, D. C. 20505
ADDRESS (INCLUDING ZIP CODE)
Qvadrvplicote -For Official Personnel Folder
Standord Form `Noy 2810
April 1969
FPM Supplement 890-1
 INSTRUCTIONS"FOR EMPLOYING-OFFICES,_
This form covers health benefits actions except enrollments, changes of coverage within a plan, and cancellations which are processed on Health Benefits
Registration Form (SF 2809). When an action requires a change in health benefits enrollment, prepare SF 2810 as soon as the effective date is known and give
the appropriate copies to the enrollee and payroll office immediately. Preparation and distribution of copies should not be delayed pending SF 50 action in the
case of transfers to another payroll office.
PROMPT ACTION REQUIRED FOR CONVERSION
To be eligible to convert to a nongroup contract, enrollee must furnish his copy of this notice to. his Plan not later than 31 days after the date shown in
Part A, item 7, or 15 days after the date. shown in Part K, whichever gives him more time. Therefore, make this form available to the enrollee as soon as
possible.
COMPLETION OF FORM
PART A--IDENTIFYING DATA
1. For items 1, 2, 3, and 6, transcribe from the lost SF 2809 or SF 2810,
whichever is the most recent.
2. Item 4, use most recent known address.
3. Item 5, use payroll office number of office authorized to process withold-
ings
4. Item 7, dote as follows for action reported in:
B. TERMINATION--Lost day of pay period in which separation (or other
action terminating enrollment) occurs except, when coverage terminates
oecause of completion of 365 days in norpoy status, use date of 365th
day; and, when coverage terminates because of military duty not limited
to 30 days or less, use date employee is separated, furloughed, or
placed on leave of absence for military duty.
C. CHANGE IN PLAN--Lost day of pay period preceding effective date of
election to change plans.
D TRANSFER OUT--Actual date.
E. TRANSFER IN--Actual date.
F. SUSPENSION--Actual date.
G. REINSTATEMENT--Actual date.
H. CHANGE IN NAME OF ENROLLEE--.Actual dote.
I. CHANGE IN ENROLLMENT--SURVIVOR ANNUITANT--Effective date of sole
survivor's annuity.
Gaining office use this box to report transfer actions; such as:
Acceptance of transfer from another agency or payroll office number
Retired--Acceptance of transfer by retirement system because employee
is eligible to continue enrollment as a survivor annuitant
Death--Acceptance of transfer by retirement system because survivor is
eligible to continue enrollment as a survivor annuitant
Transfer accepted by Bureau of Employees' Compensation.
NOTE: Retirement systems (including BEC) accepting transfer in, show also
in "Remarks'' whether enrollment is for an "EMPLOYEE ANNUITANT"
or "SURVIVOR ANNUITANT."
PART F--SUSPENSION and PART G--REINSTATEMENT
State in "Remarks'' reason for any action not applicable to active military
duty such as "Reinstatement of erroneous separation."
These most frequently occurring actions terminate enrollment with enrollee
eligible to convert to individual contract:
Separated
Furloughed by reason of reduction in force
Retired--not eligible to continue enrollment
Died--no survivor eligible to continue enrollment
Termination of title to annuity or compensation
Changed to excluded position or category
365 days nonpay status completed
Entered military duty not limited to 30 days or less
Employee organization gives notice to terminate employee's enrollment in
organization's plan.
Losing office use this box to report transfer actions, such as.
Transferred to another agency or payroll office number (do not use SF 2810
for transfer between employing offices serviced by the some payroll of-
fice number)
Retired--Transfer to a retirement system--employee appears eligible to con-
tinue enrollment as on annuitant
Death--Transfer to retirement system--survivor appears eligible to continue
enrollment as a survivor onnuitont.
Transferred to Bureau of Employees' Compensation.
Use this box only for reporting changes in name where change of coverage
within a plan by SF 2809 is not involved. Show date of birth only where
enrollment is changed from employee's or annuitant's name to name of sur-
vivor annuitant.
Only agencies administering retirement systems will make this determination
on the basis of documentary evidence that there is only one survivor an-
nuitant.
Use this box to bring to the attention of the employee, annuitant, or insur-
ance carrier any pertinent information to clarify or support the action being
taken.
ORIGINAL--Deliver (or, mail) to employee, annuitant, or survivor at earliest possible date. In case a termination SF 2810 must be issued more than 75 days after
the effective date of termination, destroy the original copy
DUPLICATE and TRIPLICATE--Send to appropriate payroll office.
QUADRUPLICATE--File in Official Personnel Folder (or its equivalent) except in cases. of death or retirement reported as "Transfer Out" to a retirement system
(included Bureau of Employees' Compensation). In latter cases, send the triplicate copy of each Health Benefits Registration Form (SF 2809) accepted from the
employee including any Medical Certificates attached thereto and this quadruplicate SF 2810 to appropriate payroll office for transmission to agency or office
administering retirement or compensation system.
 S(::ndard Forn- No. 280~~
I" _
F .TI-I BENEFITS REGISTRATION FOi
APRIEs CQNTR L NO
4,
CHAPV R 1-5 F.PM.
FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959
6 GAO )"Do
(Read h- .lions on back of lost page. Use only typewriter or ball;. r pen.)
1. NAME (LAST) (FIRSTI (MIDDLE INITIALI
2. DATE OF BIRTH
3. Are you now married?
(Use mmmbers)
PART A
7 I !
/VO -4 A/
MONTH DAY YEAS
YES 1 I
ALL WHO
'
;1 1
NO
~F
REGISTER
4. YOUR MAILING ADDRESS (NUMBER AND STREET) (CITY AND ZONE NUMBER) (STATE)
5. SEX
MUST FILL
/
y7 ) L' / j ` 141 1 r
~ v / ?
,
j `. -
MALE
FEMALE
IN THIS
_
>
6. Are you covered by, or is any family member listed below cov- 7. Place an in proper box to show your annual basic salary
PART.
ered by or enrolling in, a plan under the Federal Employees range.
Health Benefits Act of 1959 (through the enrollment of another
'
-
r
~~
(
United States or District of Columbia Government employee or UNDER $4,000 LJ~ $6,000 TO $9,999 X 3
annuitant)?
YES FA NO D $4,000 TO $5,999 [][:2] $10,000 OR OVER ^0
PART 8
11. 1 elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity
FILL 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
WISH TO EN-
NAME Of PLAN OPTION (HIGH OR LOW) ENROLLMENT CODE NUMBER
ROLL IN A
HEALTH BENEFITS
r j G% 4r I ! C ?sf A7 /
) ) t
PLAN.
2. In space below list all eligible family members 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. (Attach a. doctor's certificate for a disabled child age 19 or over.)
I!. enrollment
is for self only,
it
1
DATE OF BIRTH DATE OF BIRTH
NAMES OF FAMILY MEMBERS NAMES OF FAMILY MEMBERS
Month, Day, Year (Month
Day
Year)
answer
em
.
if enrollment
is for self and
family, also
,
,
Wife or
Husfmttd e:d-y~e.s.e..-e~-.~ ~t/n , 3 e[,t.vart,C,~~ 6
answer item 2
and item 3 If
^
it applies.
THIS PART MUST
ALSO BE FILLED
IN IF YOU
CHANGE YOUR
3 _ d above include a husband who is incapable of self-rairmy
YES
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 E
PART C
PLACE AN "X" IN ITEM I OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3.
FILL IN THIS
I. I elect not to enroll in any plan
3. The reason for my election is (Place an "X" in proper box);
PART IF YOU
WI
H NOT TO
under the Health Benefits Act.
(a) I am covered by a plan under the Health Benefits Act through the enroll- Et1
S
EN
OLL OR IF
ment of my husband, wife, or parent.
R
YOU WISH TO
2. 1 elect to cancel my present enroll-
(b) I am covered by a health insurance plan which is not under the Health El a
CANCEL YOUR
ENROLLMENT.
ment under the Health Benefits Act.
Benefits Act.
(c) Any other reason.
PART D
I elect to change my enrollment as shown by the enrollment number and other information in Part B.
FILL IN THIS
1, Enrollment code number of present plan.
2. Number of event which permits change.
3. Date of event which permits change.
PART IF YOU
(See table on back of duplicate for proper number.)
WISH TO I
y...~
MONTH
DAY
YEAR
CHANGE YOUR I
ENROLLMENT.
!~-
{.ir
6
PART E
ALL WHO
\s
.
`
WARNING.-Any intentional false statement in
REGISTER
r fem
~
this application or willful misrepresentation relative
MUST FILL
IN TH
` / ~' ez,
thereto is a violation of the low 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,)
IS PART.
(YOUR SIGNATURE-DO NOT PRINT) (DATE)
,
1. NAME AND ADDRESS OF EMPLOYING OFFICE
2. DATE RECEIVED IN
3. EFFECTIVE DATE OF
EMPLOYING OFFI
ELECTION
PART F
TO BE
,tr
COMPLET
ED
BY
3. PAYROLL OFFICE NO.
5. PAYROLL ACTION
AGENCY.
(INITIALS AND DATE)
(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)
REMARKS
FOR USE ONLY
BY ANNUITANTS
AND AGENCY.
SEPT.~1960
 INSTRUCTIONS FOR EMPLOYEES AND ANNUITANTS
(READ CAREFULLY BEFORE COMPLETING FORM)
COMPLETION OF FORM
1. All employees eligible to enroll must complete and file a Health
Benefits Registration Form with their employing office.
2. Use only typewriter or ballpoint pen. Sign Part E and submit
all copies to your employing office. Do not detach.
3. If you wish to enroll, fill in Parts A, B, and E.
4. If you do not wish to enroll or if you are enrolled and wish to
cancel your enrollment without joining another plan, fill in Parts A,
C, and E.
5. If you wish to change your enrollment from self only to self and
family (or the reverse) or if you wish to change from your present
plan or option to another plan or option, fill in Parts A, B, D, and E.
6. If you need information or help, consult the person or office
which usually advises you on personnel matters. You can also obtain
information and assistance from any office of the U.S. Civil Service
Commission.
1. If you'are an annuitant under the Civil Service Retirement Sys-
tem, the Bureau of Retirement and Insurance, U.S. Civil Service Com-
mission, Washington 25, D.C., acts as your "employing office.''
2. If your annuity is being paid by a system other than the Civil
Service Retirement System, the agency which authorizes payment of
your annuity acts as your "employing office."
3. If you are in receipt of monthly compensation under the Federal
Employees' Compensation Act and have been found unable to return
to duty, the Bureau of Employees' Compensation, Department of Labor,
Washington 25, D.C., acts as your "employing office."
4. In filling out the registration form show in the box labeled
"Remarks," your annuity (or compensation) claim number, and the
name of the agency which acts as your "employing office."
MEDICAL CERTIFICATES
1 . if you enroll for self and family and the family includes a hus-
band or a child over age 19 who is incapable of self-support because
of mental or physical disability, you must attach a certificate signed
by a doctor which gives the following information:
A. The name of your husband or child.
B. The nature of your husband's or child's disability.
C. The period of time the disability has existed.
D. The probable future course and duration of the disability.
E. The doctor's name and address.
2. The decision of your employing office concerning the disability
is final and unless your husband's or child's disability is considered
permanent, the doctor's certificate may have to be renewed from time
to time.
3. In the case of a disabled child under age 19 whose disability is
expected to continue beyond age 19, a doctor's certificate should be
filed with your employing office on or before the child's nineteenth
birthday; otherwise, he may no longer be covered as a member of the
family.
EFFECTIVE DATE
1. If you register to enroll or change your enrollment, your enroll-
ment or change generally will be effective on the first day of the first
pay period which begins not less than 14 days after your registration
form is received by your employing office, provided you were in a
pay status at any time during the preceding pay period (preceding
six pay periods for substitutes in the postal field service).
2. If you register to enroll or to change your enrollment during a
REGULAR opportunity (see Parts C and D below), your enrollment or
change will be effective on the first day of the first pay period which
begins after October 31 of the year in which the REGULAR oppor-
tunity occurs, provided you were in a pay status at any time during
the preceding pay period (preceding six pay periods for substitutes
in the postal field service).
PART A PART C
I f your wife or husband works fgr the Government, you may edch 1 If you elect not to enroll, you will have other REGULAR oppor-
enroll for self only or one of you-may enroll-for self cn'2 fomily:"1\-ra ' -1ihnifies to join a plan. The first regular opportunity will be between.
person may be enrolled both as an employee or annuitant AND as a
member of a family. (If you are covered as a member of the family
through the enrollment of your spouse or parent, you must register, but
PART B
1 . The enrollment code number you fill in shows the pion and option
in which you will be enrolled. it also shows whether you ara enroll-
ing for self only, self and family, or whether you are enrolling for
your family as a female employee with a nondependent husband.
Be sure you copy the name of the plan and the enrollment code number
frorn the brochure correctly.
If you enroll in a comprehensive plan (group-practice or indi-
viduai-practice), be sure you are in the geographic area served by
the plan; othcmiise, your enrollment' may be void and you may not be
entitled to benefits.
3. if you enroll in on. employee organization plan, you must be a
member of the organization which sponsors the plan. Your member-
ship will be verified. If you ore not a member in good standing,
your enrollment will be void and you will not be entitled to benefits.
4. After you file the registration form, you do NOT have to report
future changes in your family or in your address to your employing
office, although the plan in which you enroll --ay ask you to supply
it directly this information.
scribe additional regular opportunities to enroll at least once every
three years.
2. If you do not enroll in a plan r cancel your enrollment), you
may later have a SPECIAL opportunity to enroll, as explained under
Part D.
3. You may register to cancel your enrollment at any time. A
cancellation is effective on the last day of. your pay period following
the one in which the cancellation is received by your employing office.
PART D
1. You will have your first REGULAR opportunity to change your
enrollment from self only to family, or the reverse, or to change from
one plan or option to another between October ` and 15 of 1961,
The Civil Service Commission will prescribe additional regular oppor.
t-pities to change your enrollment at feast once every three years.
2. You may have one or more SPECIAL opportunities to change
your enrollment; or, if you previously elected not to enroll, you may
have a SPECIAL opportunity to enroii in a plan. These SPECIAL op-
portunities or granted for certain specified reasons (for example, o
change in your marital or family status), and the change must be made
within a specified time limit. A table explaining the various oppor-
tunities to change appears on the back of the duplicate of the
registration form.
PART E
If you are registering for an employee or annuitant under a written
authorization from him to do so, sign your .name . and attach the
written authorization.