DESIGNATION OF BENEFICIARY - COLLINS, CHARLES P.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: COLLINS CHARLES
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001426155
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: March 20, 2008
• Case Number: F-2007-01041
• Publication Date: January 22, 1958

standard Form No. 54
September 1954
U. S.F iP 1 Commission
15. Chapter Zl
DESIGNATION OF BENEFICIARY
FEDERAL EMPLOYEES' GROUP LIFE
INSURANCE ACT OF 1954
INFORMATION CONCERNING THE INSURED:
COLLINS
I - `~ tom'.
Charles
Prescott
DEPARTMENT OR AGENCY IN WHICH EMPLOuED (If retired, so state and give "GSA" or "CSI" number)
---------------------------------------? (Division)
---------
(Department or agency) (Bureau) nati I, the employee or annuitant identified above, canceling anyandoall previous Dthe esig b n fci s ofoB enben e e fic ~~ under
named e Federal
recei a an Group Life Insurance Act NSURANCE heretofore made by me do , a able at m,
death I understand that this Designation of Beneficiary will remain in full force and effect, with respect to an amount payable, death. ure r
iaryyshall terminate. above,
become insured as a 'retired employee, in, which ventsth sdDesignat on of Benefiagenc
uless or until e ntil such canceled by me in
or n
INFORMATION CONCERNING THE BENEFICIARY OR BENEFICIARIES; share to be paid to
Relationship each beneficiary
Type or print first name, middle initial, and last name Type or print address of each beneficiary
of each beneficiary
Va
41 __Linden_I~ane~---Fa11s__ChurCh,----Wine----
_______________ ------ All--------
_-__Anne__Vogel___Collins
And if my wife
-
s9n I_~2ne turd
J ame -------
-?-- ------------------S - - -----
--- ---------------- aaAr ------------ ------- --- ---Son-------- -.One---thir_d
,JQhny_roa_CQIl ins
- - ------- ~mP --------------------------- San------- -One-- third shar I hereby direct, unless
a shall indicated equally among the surviving beneficiaries, or ent relyeto thee urv voce I understand
that who o may predecease en shad b be distributed
this Designation of Beneficiary shall ll be void if none of the designated beneficuvries is living the time
time without knowledge or
I hereby specifically reserve the right to cancel or change any Designation of Beneficiary at any
WITNESSES TO SIGNATURE (A witness is ineligible to receive payment as a benefcia
(Signature
PRINT OR TYPE NAME ANA ADDAFSS OF INSURED
APPROVED FOR RELEASE
DATE: DEC 2007
IMPORTANT
Read instructions
on back of duplicate
before filling in this form-
(b) (3)
(b) (6)
December 28, 1916
- - - - ---------------
(City, zone nn er, and State)
------
fl State)
sty, zone number, an f
THIS SPACE RESERVED FOR R E1VING AIiENCY
IF INSURED AS AN EMPLOYEE, DELIVER BOTH COPIES TO THE PROPER OFFICER OF YOUR AGENCY-DUPLICATE WILL BE NOTED ANY?-RETURNED. 1G--70610-1
IF INSURED AS AN ANNUITANT, SEND BOTH COPIES TO THE CIVIL SERVICE COMMISSION, WASHINGTON 25, D. C.-DUPLICATE WILL BE NOTED AND RETURNED.
 IMPORTANT.-The filing of this form will completely cancel any Designation of Beneficiary under the Federal
Employees' Group Life Insurance Act you may have previously filed. Be sure to name in this form all persons you wish
to designate as beneficiaries of any group life and accidental death insurance payable under that act at your death.
EXAMPLES OF DESIGNATIONS
Type or print first name, middle initial, and last name
of each beneficiary
Type or print address of each beneficiary
Relationship
p
to be paid to
each beneficiary
Mary E. Brown*
-------------------------------------------------
------------------- --------------------------------------------
214 Central Avenue, Muncie, Ind.
----------------------------- ---
----- - ---- --------------------------------------------------------------
Niece
------------------
---------------
All
----------------------
----------------- -----
Type or print first name, middle initial, and last name
of each beneficiary
Type or print address of each beneficiary
Relationship
Share to be paid bo
each beneficiary
Alice M Long
-------- -------- ----------------
509 Canal Street, Red Bank, N. J.
-------------------------------
Aunt
-------------------
One-fourth
--------------
--
~: J f17. V }'..i
.__ ice`
-
-----
Joseph--P.---Brady
360 Williams Street Red Bank --N.---J .
Nephew
One-fourth
Catherine--L.---Rowe
792 Broadway, Whiting, Ind.
Mother
.,--One-ha'lf
Howl 'TODESIONATE A 'OONTINGENT BENEFICIARY
Type or print first name, middle initial, and last name
of each beneficiary
John M. Parrish, if living
Type or print address of each beneficiary
Share to be paid to
each beneficiary
Type or print first name, middle initial, and last name
of each beneficiary
Type or print address of each beneficiary
Relationship
p
Share to be paid to
each beneficiary
Cancel prior designations
--- - --------
----------------------------- - ----
------ - - - ------------------------------------------------------------
--- - ---- - -- - --------- - --------------------
- - -------------
--- - ------- - ---
-----
--- - -
*Do not write name as M. E. Brown or as Mrs. John H. Brown. 10-70610-1
**Be sure that the shares to be paid to the several beneficiaries add up to 100 percent.