[1]| NW 88326
[3]Assassination Records Review Board
[4]Final Determination Notification
[6]AGENCY : HSCA
[7]RECORD NUMBER : 180-10068-10324
[8]RECORD SERIES : STAFF PAYROLL RECORDS
[9]AGENCY FILE NUMBER :
[11]December 8, 1995
[12]Status of Document: Postponed in Part
[14]Number of releases of previously postponed information: 8 .
[16]Reason for Board Action: The Review Board's decision was premised on several factors
[17]including: (a) the significant historical interest in the document in question; (b) the
[18]absence of evidence that the release of the information would cause harm to the United
[19]States or to any individual.
[21]Number of Postponements: 4
[23]Postponements: All the postponements in this document represent Social Security numbers.
[25]Reason for Board Action: The text is redacted because the public disclosure of the redaction could
[26]reasonably be expected to constitute an unwarranted invasion of personal privacy, and that invasion of
[27]privacy would be so substantial that it outweighs the public interest.
[29]Substitute Language: SSN
[31]Date of Next Review: 2017
[33]Board Review Completed: 10/24/95
[35]| Docld:32243290 Page 1
[37]oe, ge Date:08/20/93
[39]JFK ASSASSINATION SYSTEM
[41]IDENTIFICATION FORM
[43]AGENCY INFORMATION
[45], AGENCY : HSCA
[46]RECORD NUMBER : 180-10068-10324
[48]RECORDS SERIES :;:
[49]STAFF PAYROLL RECORDS
[51]- AGENCY FILE NUMBER :
[53]ORIGINATOR :
[54]FROM :
[55]“TO 3
[57]TITLE :
[59]12/29/77
[60]8
[62]DATE
[63]PAGES
[66]_ HSCA, ADMINISTRATION
[67]COLLINS, WENDY S.
[69]DOCUMENT TYPE PRINTED FORM
[71]CLASSIFICATION : U
[72]RESTRICTIONS : 3
[73]CURRENT STATUS : P
[74]DATE OF LAST REVIEW : 07/07/93
[75]OPENING CRITERIA :
[76]COMMENTS :
[77]Box #:1.
[78]| . ([R] - ITEM IS RESTRICTED
[79]| NW 88326
[81]| Docld:32243290 Page 2
[83]- LOUIS: STOKES, OHIO, CHAIRMAN
[85]7 a ae eS
[87]- RICHARDSON PREYER, N.C. _.. SAMUEL L. DEVINE, OHIO ae
[88]L tWALTERE. FAUNTROY, D.C. - STEWART B, MC KINNEY, CONN, ° x o¥
[90]“YVONNE BRATHWAITE BURKE, CALIF, CHARLES THONE, NESR. : : :
[92]_ | CHRISTOPHER J. DODD, CONN, HAROLD S. SAWYER, MICH. | : . . : 7
[93].| {HAROLD E, FORD, TENN, _ . . 7 q ig ;
[94](0 ShReOYD ac FITHIAN, IND _. Select Committee on Assassinations —
[95]\ SUROBERT: W. EDGAR, PA. : cet . mo .
[96](202) 225-4624 + U.S, House of Representatives
[97]7 co ; a 3369 HOUSE OFFICE BUILDING, ANNEX 2
[99]J ' WASHINGTON, D.C, 20515
[101]- December 5, 1978
[103]“The Honorable ‘Frank Thompson, Jr.
[104]Chairman.
[106]- Committee on’ House Administration
[107]. ‘U. S. House of Representatives
[108]| - - Washington, D. C. 20515
[109]‘Dear Mr. Chairman:
[110]. Effective December 1, 1978, the official duty station of Ms. Wendy
[112]"collins has. been changed from Washington, D.C. to Pittsford, ‘Vermont.
[114]“LS:th
[116]“This change will remain in effect through the balance of the 95th Congress.
[119]PAYROLL AUTHORIZATION FP°M
[121](Please Use Typewriter “>. wv - U.S. HOUSE OF REPRESENTATIVES“ (Any erasures, corrections, or changes. *.~:
[123]Washington, D:C. 20515 on this form must be initialed by the
[125]or Ballpoint Pen) — authorizing official.)
[127]To the Clerk of the House of Representatives:
[129]| hereby authorize the following payroll action:
[131]Employee Name (First-Middle-Last) : Ty | Effective Date
[133]Type of Action
[135]O Appointment
[136]0 Salary Adjustment
[137]0 Title Change
[139]Termination (At close of business on effective date)
[141]CO Leave without pay (Beginning with effective date above and ending
[143]close of business
[144]. Specify Date
[146]- (If type of action is an-Appointment, Salary Adjustment, or Title Change, complete ‘appropriate information below.)
[148]Position Title
[150]Gross Annual Salary *
[152]wb
[154]Dey i
[156]* If employee is a civil service annuitant (includes U.S. House: of Representatives), the gross annual salary shown should include the annuity received by the employee -°
[158]plus the salary received from the employing office.
[160](If Committee Employee, complete appropriate item below.)
[162]1.0 — Stoning Committee: Staff—O Clerical or 1 Professional.
[164]Mg, ny
[166]2" Congress.
[168]3. O Joint Committee.
[170](If Employee of an Officer of the House, complete item below.)
[172]Position Number If applicable, Level
[174]| certify that this: authorization is not in violation of 5 U.S.C. 3110(b), prohibiting the employment of:
[176]relatives.
[177]Dote__ 7) ae
[178](i appropriate, signature of Subcommittee Chairman or Ranking Minority Member) ~~ = "(Type or print name of Authorizing Official)
[179]. GBA s PER
[180](Type or print name and title of above official) ~ eee Title vif Member, DistrictandSiote)SStCSCSC~CS ~
[182]> All appointments and salary adjustments for employees under the: House Classification Act and for Committee em-
[183]ployees; except those of the Committee on Appropriations; the Committee on the Budget,-and the Joint Committees, must ™
[184]be approved by the Committee on House Administration.
[186]APPROVED:
[188]Chairman, Committee on House Administration
[190]Office of Finance use only:
[192]Office Code
[196](Revised: August | 1977)
[198]On yas SORE Sta oe
[200]“
[202]se abbdie rt Cae,
[204]Sead
[206]A cecal Lee ate a thet
[208]one ee
[210]PAYROLL AUTHORIZATION FORM
[211]‘(Please Use Typewriter .- . U.S. HOUSE OF REPRESENTATIVES . .. (Any.erasures, corrections, or changes:
[213]_ authorizing official.)
[215]To the Clerk of the House of Representatives:
[217]| hereby authorize the following payroll action:
[219]Employee Name (First-Middie-Last) ~~. ~~” Effective Date 8° |
[221]fAppointment
[223]{] Salary Adjustment
[225]O1-Title Change
[227]O1 Termination (Ai close of business on effective date}
[229]Cl Leave without pay (Beginning with effective date above and ending
[231]close of business
[233]. Position Title
[235]Re Soarea Abtarney
[237]- * If employee is a: civil service annuitant (includes U.S. House of: Representatives), the gross annual salary shown should include the annuity réceived bythe employee” .
[239]plus the salary received from the employing office.
[241](If Committee Employee, complete appropriate item below.)
[243]1.0 Standing Committee: ‘Staff—O Clerical or 0 Professional.
[245]Congress.
[246]3. O Joint Committee.
[248](If Employee of an Officer of the House, complete item below.)
[250]Position Number If applicable, Level_______.. Step______
[252]I certify. that this authorization is not in violation. of 5 U.S.C. 3110(b), prohibiting the employment’ of.
[253]relatives.
[255]All appointments and salary. adjustments for employees under the-House Classification Act and for Committee em-"
[256]: ployees, except: those of the Committee on Appropriations, the: Committee on the Budget, and: the Joint Committees, must
[257]be approved by the Committee on House Administration.
[259]APPROVED:
[261]Chairman, Committee on House Administration
[263]Office of Finance use only:
[265]Office Code
[267]or Ballpoint Pen) ~~ Washington, D.C. 20515 on this form must be initiated by the
[269]Chenne e thle  e
[271]ne nae Cena nO RAE aS OE
[275]tor labeBeccle at wan 4
[277]tS wee
[279]tafe ET ra
[283]ce
[285]ee 8 8 8 OL
[287]“1976=599-393 2, iss
[289]vans
[291]New Carrier’s Control No.
[293]FEDERAL BENETTS REG BENEFITS PROGRAM 22933 iW) ¢
[295](Read instructions on back of page 3.).
[297]. _ : Old Carrier’s Control No.
[298]_ TO EMPLOYING OFFICE: SHOW OLD CARRIER’S.CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL .
[299]ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN.
[301]1. NAME (LAST) - . (FIRST) . (MIOOLE INITIAL) 2. DATE OF BIRTH | 3. ARE YOU NOW
[303]PART A a To ; S (Use numbers} _| | MARRIED?
[304]Co lhws WI2nm D1 . . .
[305]ALL WHO REGIS- 4. YOUR MAILING belo a. (NUMBER AND STREEF) LO : S % , Yes Cit]
[306]TER MUST FILL a L. . , j
[307]NtaspaRT. | 1630 | Helo A :
[308]cerry) (STATE) (z1P CODE) ; 5. SOCIAL SECURITY ~ | 6.Sex
[309], ACCOUNT NUMBER . MALE CIb]
[311]fo Waswmgien DC ey, 29 -ery-syo remelOt
[313]IMPORTANT
[316]“tTISTLLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. 4F YOU ARE ALREADY COVERED THROUGH
[317]~. | THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER
[318]- | ENROLLMENT MUST BE CANCELED OR CHANGED TO SELF ONLY. SIMILARLY, 1F A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR. HER) OWN
[319]ENROLLMENT, YOUCANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES. 2 AND 3.
[321]PART B 1.. telect to enroll ‘in a health benefits plan as shown below. | authorize deductions from my salary, compensation, or annuity to cover my _
[322]share of the cost of the enrollment. - (Copy the information requested below from back page of brochure of the plan you select.)
[324]FILL IN THIS | [Name oF ue ; —_ oT OPTION (HIGH OR LOW)
[325]PART. IF YOU Blue C ass /f / Blue Slyeld S@euice Mert av /
[326]: ca : H '
[328]WISH TO ENROLL.
[330]OR CHANGE
[332]YOUR ENROLL: 2. In space below list all mi ban members without exception: . List your wife or husband first, then your unmarried children under age
[333]a .« 22, including (a) legally adopted children and (b)- stepchildren; foster children, and illegitimate. children.who live with you in a regular
[334]MENT IN A parent-child relationship. -Include also any unmarried child over 22 who became disabled before age 22 and who, because of the disability
[335]“HEALTH BENE . is ‘incapable of self-support.. (Attach a doctor's certificate for a disabled child age 22 or over, if one is not already on file.) DO NOT LIS
[336]one ‘ “> 7 “PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. THEY: WILL NOT RECEIVE BENEFITS, EVEN IF THEY
[337]FITS PLAN. ‘ ARE DEPENDENT ON YOu AND.ARE LISTED.
[339]¢ ae ‘ ES OF FAMILY ‘ME E s OATE OF BIRTH NAi F-FAMILY MEMBE RS DATE OF BIRTH
[340]If enrollment is “de ‘ Nam Ss an A WLY: Me ® . 4 2 {Month, Day, Year) MES O AMIL (Month, Day, Year) ia
[342]for Self Only,
[343]answer. item 1. .
[344]If enroliment.is.
[345]. for Self and
[346]Family, also an.
[348]Wife or *
[349]Husband
[351]CHANGING YOUR
[352]ENROLLMENT
[353]ALSO FILL’ IN
[354]PART D.
[356]PART Cc . PLACE AN ‘’X'" IN ITEM 1 OR 2 WHICHEVER APPLIES:
[358]. , 4, LELECT NOT TO ENROLL 'IN A PLAN UNDER THE FEDERAL - 2:: (ELECT TO CANCEL MY PRESENT. ENROLLMENT: UNDER THE.
[359]FILL (IN.-THIS]| - EMPLOYEES HEALTH BENEFITS PROGRAM: nos - CODE NUMBER SHOWN BELOW
[361]PART 1IF YOU . . : a . -
[362]WISH NOT TO! ... ‘ a . : me Present Enrollment Code Number . an .
[363]ENROLL OR-IF{: oe we . Ce : . : \f you elect to cancel |
[364]YOU WISH TO]. ~~ - Te : be sure to read
[365]; ,CANCEL YOUR so : : "Cancellation-of Enroilt-
[366], EN ROLLMENT.: coe _ an ; ‘ment’ on back of page 3.
[367]’ PART D ANSWER. 1 TEMS 1; 2, AND 3 TO SHOW-ENROLULMENT CODE BEING CHANGED AND ELIGIBILITY FOR.CHANGE.
[368]. ~ ons 1, ENROLLMENT CODE NUMBER’ 2 4 , | 2,, NUMBER OF EVENT WHICH PERMITS CHANGE, | 3. DATE OF EVENT WHICH PERMITS CHANGE.
[369]CF LL . IN THIS 7 OF PRESENT-PLAN. toe - (See table on back of page 2 for proper number,)..
[370]PART, AS WELL Se *
[372]AS PART B, TO
[373]CHANGE YOUR
[374]REGISTRATION.
[376]‘PART E Se i” . , ae oO WARNING.— Any intentional false statement:
[377]; oo, ” . : oo 0 io a i = in this application or wilful misrepresentation
[378]: er oe Ly Z yy a ro . relative thereto. is a violation of the Jaw
[379]. TER MUST ELT A 7”, 5» * ; io yo A punishable by a fine of not more than $10,000 |
[380]"IN THIS PART...-| -& ¢ W474, . i i : or imprisonment of not more than 5S years,
[381]a aan (YOUR/SIGNATURE. DO NOT PRINT) : a * | or both. (18-U.S.C. 1001.) © pe
[382]; ‘}4. NAME AND ADDRESS AINCLUDING ZIP CODE}OF EMPLOYING OFFICE... - + [2. DATE RECEIVEO IN © | 3. EFFECTIVE DATE OF
[383]: a ; ” oo ; EMPLOYING OFFICE -|. ELECTION
[384]PART F U.S. House of Representatives |
[385]COMPLETED Office. of Finance : Washington, D. C. . 20515.. 4. PAYROLL OFFICE NO, |5. SF 2811 REPORT NO..
[386]BY AGENCY | , , ,
[388]| ASIGNATURE OF AUTHORIZED AGENCY OFFICIAL)” :
[389]REMARKS | a
[390]- FOR USE ONLY .
[391]BY AGENCY. . . fo ; me . . .
[392]‘NW 88326— —_ : Standard Form No. 2809
[394]Docld:322433550 Page 6 _ Page 1 — To Payroll Office US Gi Sepplemene 890.1
[396]munmkhar
[398]Wie
[401]|Poo  iteyp
[405]ewriter is not available, bear down with ball-point pen to make legible copies:
[407]HEALTH BENEFITS REGISTRATION FORM — _ | New Carrier's Contra! No.
[408]FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM =
[409](Read instructions on back of page 3.) ” C
[411]TO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL: NUMBER ONLY IF ELECTION 1S"TO CANCEL
[412]ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN,
[414]3. ARE YOU NOW
[415]MARRIED?
[417]| 2, DATE-OF BIRTH
[418]{Use numbers)
[420]1, NAME (LAST) (FIRST) me, -  “(MIDOLE INITIAL)
[422]S ,
[424]“- PARTA |
[426]4. YOUR MAILING ADDRESS. : (NUMBER AND STREE/T)
[428]| ACL WHO REGIS.
[429]TER MUST FILL So {) -
[430]IN THIS PART. = in NM. —
[432]T 5. SOCIAL-SECURITY,
[433]COUNT NUMBER!
[435]Yer S716"
[437]. a Pen) s “IMPORTANT 0 ee wo
[438]“IIS ILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF YOU'ARE ALREADY COVERED THROUGH - -
[439]THE FAMILY. ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER
[440]ENROLLMENT MUST 8E CANCELED OR: CHANGED TO SELF ONLY. SIMILARLY, !F A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS {OR HER) OWN: J.
[441]ENROLLMENT; YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE .FAMILY MEMBER CANCELS HIS (OR HER} ENROLLMENT. ALSO SEE BACK OF PAGES.2 AND.3.; }
[443]PART B -
[444]FILL IN” THIS
[445]| PART IF YOU
[446]“}” WISH TO ENROLL
[447]‘OR CHANGE
[449]MENT. PNAS
[450]> | HEALTH BENE-
[451]] FITS PLAN. ..
[453]‘ 1 1 elect to enrollina health benefits plan as shown below. | authorize deductions from my salary, compensation,’ or ‘annuity to cover-my
[454]share of the cast of the enrollment. (Copy the information requested below from back page of brochure of.the plan you select.) .
[456][Bane oF Puan rn SGaROLLMENT COBENUMEER] |
[457]Blue ross J Blue Sluield SCéwice 7 io /
[458]enehR} Plan -_- ae YP oF tO wt,
[460]_ 2. In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age
[461]_ 22, including ‘{a) legally adopted children and (b) ‘stepchildren, foster children, and ille itimate children who live with you in a regular’
[462]. parent-child reldtionship.. Include also any unmarried child over 22 who became disabled before age 22'and who, because of the disabitity
[463]“Is incapable of self-support. (Attach a doctor's certificate for a disabled child age 22 or over, if one is not already on file.) DO NOT List en
[464]-PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. THEY WILL NOT RECEIVE:-BENEFITS, EVEN IF THEY, ode
[465]ARE DEPENDENT ON YOU AND ARE LISTED. _ . anes ees De
[467]DATE OF BIRTH
[469]OPTION (HIGH OR LOW)
[471]DATE-OF BIRTH °' .
[472](Month, Day, Year’
[474]If enrolimentis -
[475]for Self Only,”
[476]answeritem 1.
[477]-. H enrollment is
[478]for. Self and
[479]| Family, also an-
[480]Vo sweritem:2. |.
[482]_ “NAMES OF FAMILY MEMBERS ,
[484]‘| Wife or
[485]‘Husband
[487]PIF YOUARE
[489]-| CHANGING YOUR
[490]“| ENROLLMENT.
[491]‘+ ALSO “FILL. IND
[493]; “ - PART C: . PLACE AN"X" _,
[494]ALL AN THIS eee ee ee WRGeNercrs PROGRAM | a
[495]“WISH NOT’ TO; : oo. ; : mo ae
[496]-} ENROLLED OR SFP ae ; _ i : .If you elect to cancel
[497]YOU WISH TOT. |... . . . . ; oo een oo be sure to read . Doo
[498]“CANCEL: YOUR | - “Cancellation of Enroll-
[499]ENROLLMENT: |: _ment’! on back of page 3. |
[501]| PARTD
[502]FILL -IN. THIS
[503]PART, AS WELL |
[504]AS PART.B, TO
[505]CHANGE YOUR
[506]REGISTRATION.
[508]“; ELECT TO CANCEL MY PRESENT. ENR
[509]CODE NUMBER SHOWN BELOW: — :
[511]LIGIBILITY FOR.CHANGE.
[513]> NUMBER OF EVENT WHICH PERMITS CHANGE.
[514](See tabla on back of page 2 for proper number.)
[516]4: ENROLLMENT CODE N
[517]"- OF, PRESENT PLAN
[519]UMBER’ 3. DATE OF EVENT WHICH PERMITS CHANGE.
[521]YEAR |
[523]_WARNING.-— Any intentional false statement |
[525]in this application or wilful misrepresentation
[526]relative thereto is’ a violation of the law
[527]punishable by a fine of not more than $10,000
[528]or imprisonment ‘of not, more than 5 years,
[529]or both (18 U.S.C, 1001.) -
[531]3. EFFECTIVE DATE OF .
[532]“ELECTION . ;
[534]PARTE |
[535]ALL WHO REGIS. .
[536]“TER MUST FILL:
[537]IN THIS PART.
[539](YOUR SIGNATURE. .DO NOT PRINT) 3 (DATE)
[541]14. NAME ANO-ADDRESS {INCLUDING ZIP CODE) OF EMPLOYING OFFICE
[543]2. DATE RECEIVEDIN
[544]EMPLOYING OFFICE
[546]|. | PARTF | -y.s, ouse-of Representatives — oo
[547]|. TO UE LETED Jf. Office Or. Finance, Washington ,. DeGo, . 205215 . [a PAYROLL OFFICE NO. s
[548]‘| BY AGENCY | re OO .
[550]: — —— | - 90004832
[551](SIGNATURE OF AUTHORIZED.AGENCY OFFICIAL) — po Co
[553]Tron useoney] 0 ee | 7 oes
[554]Wi ~ 4D _ - . : . : Jo . , vo: : : “s ” an a 7 a ne oy : 7 : "ot a. = ; tole
[555]WW 88226 - : “ — “" Standard Form No. 2809 °°
[556]Boch: 3224839 (Page F-
[558]. . Page 2 —_ To Insurance Carrier . : : . U.S. Civil Service Commission
[561]HEALTH BENE ris SEeTPATIONSORE i .New — ofS
[562]7 FEDERAL EMPLOYEES HEALTH BENEFIT! CoN. rouere) am
[563]© (Read instructions .on back of page 3.) &) : l2 2 9 3 38 20)
[565]. : _Old Carrier's Control No. ,
[566]TO EMPLOYING OFFICE: SHOW OLD CARRIER’S CONTROL NUMBER ‘ONLY IF ELECTION is TO CANCEL Ot aor F
[567]ENROLLMENT OR TO'CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN. . . ; a
[569](inst Sa Garboce INTIAN 2 DATE OF BIRTH . [3 ARE YOU NOW.
[570]_ co. se * (Use numbers) “MARRIED? ° : Co . os
[572]. Oy . - SO \
[574]ALLWHO REGIS- . : ) (NUMBER AND street)
[576]: : wh 5 4 Cp é .
[578]TER MUST FILL | jc.) Jvtulbsace th oP, Ad bap
[580]LIN THIS PART: —_— ——— —_——— - -
[583]Is ILLEGAL! FOR AN EMPLOYEE OR A MEMBER OF HiS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. 1F ‘YOU ARE ALREADY COVERED THROUGH .
[584]THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE-OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR’ THE OTHER
[586]ENROLLMENT MUST BE CANCELED OR CHANGED TO SELF ONLY. SIMILARLY, 1F A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS [OR HER) OWN :
[587]ENROLLMENT, YOUCANNOTELECT A FAMILY ENROLLMENT-UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES 2 AND 3.
[589]. PART B ‘ 1. Velect to enroll ina, health: ‘benefits plan as shown below. | authorize déductions from my salary, compensation; or annuity to cover my.
[590]5 “
[591]: . ‘ share of the cost of, the’ enrollment.
[593]oa ae (Copy the information requested below ‘from back page of brochure of the plan you select.) - ;
[594]FILL IN THIS: AME. OF PLAN Sn ; a Beye —_ OPTION (HIGH OR LOW) | | ENROLLMENT CODE. SNUMGER
[595]‘PART. IF YOU ged. Eero ad © A Pa e ot, aed AEE yes el, bhp at pads 7 —— _
[596]WISH:TO ENROLL a Cope yt AE ne Of] PREG
[598]“OR CHANGE, : “* J
[600]YOUR EN ROLL-.  2.01n space “below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age .
[601]7 - .22; including (a) Jegaily adopted children and (b) stepchildren, foster children, and- Megitimate children who live with you-in a regular:
[602]MW ENT IN A _. | parent-child relationship. “Include also any Unmarried child. over 22 who became disabled
[604]efore age. 22 and who, because of the gisabil ity. “
[605]WEALTH. BENE- . . is incapable of.self-support. - (Attach a doctor’s certificate for a disabled child a Ss
[608]; FeAE ns Z|. 7 a \
[612]le 22 or over, if one is not already on file.) DONOT LIST. .
[613]PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. Tt EV. WILL NOT RECEIVE. “BEN FITS, EVEN: iF THEY.”
[614]“| FITSPLAN. -ARE DEPENDENT ON YOU AND ARE LISTED. |
[615]pe co . .. "DATE OF BIRTH a : ; “+ DATE OF BIRTH
[616]it enrolment is Po NAMES OF FAMILY MEMBERS “| (Month, Oav:-¥ear) | NAMES OF FAMILY MEMBERS © 5"/. (Month, Day, Year!” ay
[617]| for Self Only, —— — > een Os
[618]~answer itém 1, ~' vite or re 0 qt tty . rr _ \
[619]Hfenrolimentis, L . : ' : : | : a - * a ae : _ “| - : ; \
[620]‘for ‘Self and |) |= Dr 7 Ce , ue oe ng re 2 | \
[621]Family, also an- -] °°. : ae Poo, . woe, . oo re Set ! tres \
[622]- sweritem 2... -——-— SS - -
[624]IF YOU-ARE
[625]‘CHANGING YOUR
[626]ENROLEMENT
[627]4) ALSO" FILL. -
[628]PART D.”
[630]“PART. Cc’ {PLACE AN ‘'X” IN ITEM 1 OR'2 WHICHEVER APPLIES:
[632]1, VELECT.NOT TO-ENROLL IN A PLAN UNDER THE FEDERAL 2:
[633]FELL IN. THs |! “EMPLOYEES HEALTH BENEFITS PROGRAM, .
[634]~PART.-1F. YOU . .
[636]+ WISH NOT TO]... Hienen Be
[637]ENROLL. OR TE) . re ; _ a Co, ; . ie ; , ‘If you.elect to cancel
[638]YOU. WISH TO 0 a ; ; _ : : .. | |-besure-to read:
[639]‘CANCEL. YOUR rr ee -_ oe . P a : : Cancellation. of Enroll-'
[641]ut . . ps . : ‘ment’ on back of page 3.
[643]| ELECT TO ‘CANCEL MY. PRESENT ENROLLMENT UNDER THE
[644]CODE NUMBER SHOWN BELOW:
[646]ANSWER ITEMS 1, 2, AND 3° TO SHOW ENROLLMENT CODE BEING CHANGED AN D> ELIGIBILITY FOR CHANGE, .
[647]Teneo: io. | 1. ENROLLMENT CODE NUMBER - 2. NUMBER OF EVENT WHICH PERMITS CHANGE. |3. DATE OF EVENT WHICH PERMITS CHANGE. |.
[648]-FILL .IN THIS i “OF PRESENT PLAN : (See table on back of page 2 for proper number.)
[649]PART,AS WELL] “oy a - ; per nu
[650]_ | AS PART B,.TO.
[651]REGISTRATION.
[653]“PART E. “WARNING.—Any intentional false statement | -. - t
[655]. . 7 : woo ; -- ‘ oo . in this application or wilful misrepresentation | ~ ..-
[657]a a ee es whe ; “| relative thereto is a. violation of the law °
[658]onc “ a A oe rs _ | punishable by a fine of not more than$10,000.| ~~: -
[659]IN THIS PART : or ‘imprisonment of- not more than’ 5 “years,
[660]ee Sor both: (18 U.S.C.-1007.).
[662]. DATE RECEIVEDIN | '| 3. EFFECTIVE ‘DATE OF. al a . |
[663]oo _ EMPLOYING OFFICE a . ELECTION | . . . .
[664]PART F
[665]COMPLETED - oe EEE 2. | & PAYROLL OFFICE NO. |S. SF 2811 REPORT NO, . -
[666]‘BY AGENCY . oe . oo oo . : ,
[667]REMARKS fo a a
[668]- FOR USE ONLY : , 7 a ; . . .
[669]BY AGENCY. ooo ee - | . .
[670]lSwee o8326~ | ee aed Farm Nor SOOO
[671]| Docld:33923250" Page 8 Page 3 — For Official Personne! Folder ; U.S. Civil Service Commission
[673]FPM Supplement 890-1
[675]“NW 88326 7 - oe
[677]| if f typews iter is no 2 vailable, ‘bear down with ball-point. pen to make legible copies. :
[679]EDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
[681]__ (Read instructions on back of page By ; ve - 22 3 3 3. 8 20 :
[683]Old Carrier's Contro! No.
[684]‘To. EMPLOYING OFFICE: SHOW OLD ‘CARRIER’S CONTROL.NUMBER ONLY IF ELECTION 1S TO CANCEL re Tos
[685]ENROLLMENT OR-TO CHANGE OPTIONS OR. TYPE OF,ENROLLMENT IN THE SAME PLAN,
[687]1.NAME. © (LASTD Dee (FIRST) .-
[689]. (MIDDLE INITIAL) | 2. DATE OF BIRTH ~ 3. ARE. YOU NOW
[690]oo - (Use numbers) © “MARRIED?
[692]|, "ALL WHO REGIS.
[693]TER MUST FILL.
[694]IN THIS PART. -
[696]“IMPORTANT |
[698]Tis tCLLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO: BE COVERED UNDER MORE THAN ONE ENROLLMENT. AF YOU ARE ALREADY COVERED THROUGH:
[699]._ THEFAMILY ENROLLMENT OF ANOTHER FEDERAL OR. DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT. ‘YOU MUST: REGISTER NOT TO ENROLL OR: THE OTHER®*
[701]ENROLLMENT MUST BE CANCELED.OR CHANGED. TO SELF ONLY. SIMILARLY,1F. A FAMILY MEMBER LISTED BY YOU IN:PART B IS COVERED THROUGH HIS4{OR HER) OWN ~
[702]L ENROLLMENT. “YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES. 2. AND:3,
[703]; | 1. lelect-to- énroll in a health benefits plan as shown below.
[704]i PART BL ‘ ‘share of the cost. of the enrofiment.,
[705][FILL IN. THIS
[707]NAME OF PLAN . - . ; oo, 2 OPTION (HIGH OR LOW) | [ ENROLLMENT CODE NUMBER]
[708]PPaRT (F YOU} |; «0 fe APR eR ae LAD tae ceo ;
[710]| WISH TO-ENROLL | | °°. pop ee
[712]“ORSCHANGE
[714]‘ ‘YOUR ENROLL- 2. In Space below. list ail eligible family members without-exception: List your wife or husband first, then your. unmarried chitdren ‘underage’.
[716], wh. - 22, including (a)- legaily ‘adopted ‘children and (b) ‘stepchildren, foster ‘children, and illegitimate ‘children. who live. with you in-a regular ~~
[718]TMENT--UN A * parent-child relationship. ~Inctude also: any unmarried child over 22 who became disabled before age 22 and-who, because of the disability,
[719]“HEALTH ‘BENE- _ is incapable.of. self-support: ‘
[721](Attach. a doctor's certificate for a disabled child age:22-or over, if one is not already on‘file.). DO.NOT LIS
[722]-PARENTS OR. OTHERS.WHO ARE-NOT ELIGIBLE FAMILY MEMBERS. Tv EY.WILL NOT RECEIVE: ‘BEN FITS, EVEN: F THE?
[724]“| authorize deductions from my salary, compensation,” ‘or annuity to cover my...
[725](Copy the information requested below from back page of brochure of the plan. you select. )
[727]i
[729]FITS PLAN... | ARE DEPENDENT ON YOU AND ARE LISTED
[731]: ae | . DATE OF BIRTH a , . . ; - 70 J) paATE-oF BATH |
[732]| ifenrotimentis “|. NAMES OF FAMILY, MEMGERS! (Month, Day: ¥ear) . NAMES OF FAMILY MEMBERS an hee intonth, Day, Year)
[733]{> for Self Only, © [7 ; . — —_ : : :
[734]= . answer item 1,
[735]‘tfenroliment is -
[736]for Self. and
[737]| Family, also an-
[740][t1F YOUARE
[741]CHANGING YOUR
[742]ENROLLMENT
[743]ALSO FILL IN’
[745]: PLACE ANI X! IN ITEM 1 OR 2 WHICHEVER APPLIES:
[747]PHIS |. EF M. Soap oss pee CODE NUMBER SHOWN BELOW:
[748]“PART. Ne YOU}: ; : ; . ba a an me
[749][wish Nor TO] te ~ df ee ee mo}
[750]“ENROLL ORUIFP Bete 7 TN a 7 Po - . | tf you. elect to cancel:
[751]YOU: WISH TO oe eG . _ ae ‘ . be'sure to read. ot
[752]U "Cancellation of Enroll-:
[753]ment” of back of page 3:
[755]ANSWER ITEMS 2, AND’3 TO SHOW ENROLLMENT.CODE ‘BEING CHANGED AND ELIGIBILITY FOR CHANGE. -
[757]7 IN THIS: EN ROLUMENT CODE. NUMBER aa Fii $s ph 2. NUMBER OF EVENT WHICH PERMITS CHANGE. 3. (DATE: OF EVENT WHICH PERMITS CHANGE:
[758]Lue OF PRESENT: PUAN = - epoe e (See table on back of.page 2 for. proper-‘number.)}. . a
[760]PART, AS WELL.|:: - ; : .
[762]AS PART: B, TO
[764]CHANGE YOUR |"
[765]‘REGISTRATION.
[767]PART ES
[769]' a ae ae : _ , fo ; in this application or wilful: misrepresentation |
[770]| ALL WHO REGIS. (eg Ou 8 be |
[772]; So . | relative thereto is a violation of - the’ law. bo.
[773]_| TER Must FILL : _ ; 7 a A . 2 - ; ; 7 oa - | punishable by a fine of not.more than $10, 000 | ~
[775]or. imprisonment of not more than 5. years,
[776]or both (18 U.S.C: 1001.) |
[778]}2. DATE:RECEIVED IN «=». | 3.* EFFECTIVE DATE. OF: :
[779]' EMPLOYING OFFICE a oa ELECTION
[781]“. PART F-
[783]TO BE a 2 : 3 | =
[785]> COMPLETED |. °° : ee “ee mon PAYROLL OFFICE NO. 15. SF 2811 REPORT NO.
[786]BY AGENCY | J oo _ ne _ .
[788]_ REMARKS”
[789]"FOR. USE: ONLY |...
[790]BY: AGENCY.
[792]‘Standard Form No. 2809
[793]2809-115-01 U.S. Civit Service Commission
[794]FPM Supplement 890-1 ~
[795]November 1972 -
[797]-H : ALTH. BENEFITS REGISTRATION’ FORM - ; New Carrier's Control No.
[799]_ WARNING.—Any intentional false statement pos
[801]1d:32243290 Page 9 : on |
[804]- +
[805]ce eer nt et a eee eee
[807]W 88326 oe
[808]1d:32243290 Page 10 : rs ;
[810], Check the appr opriate pox te to the right:
[812]PAYROLL INFORMATION FORM AND PERSONNEL AFFIDAVIT
[814]PLEASE USE TYPEWRITER OR PRINT IN INK
[816]CODE:
[817]| Finance Office Use Oniy | U. S. HOUSE OF REPRESENTATIVES
[819]U.S. House -
[820]Employing Office Select toe — al
[821]‘ BSS ASSET ORS | a
[823]Social Security No. 2 2 <4 S/e G 3 Date of birth ___O go 2e2- S34
[825](Month —Day— Fe: ary .
[826]a See ee es
[828]_ ADDRESSES: a ee a
[829]"Mailing address for p roll ch ( ik: home, fice, e
[831]“ oe vee ng ac ress fo payroll pec (Boh oa e ice, jetc.):
[833]i Soleute Capua ce a
[835]wr a oe
[838]Mailing: address for withholding tax ‘Statement
[840]FINANCE OFFICE USE ONLY
[842]Sntaprete ats tks Bank.Code: Eee RS a eae S “RT le Be ; «Ba: not.. cart ‘Bank. -Account .Number' unless check
[843]i . J is # to ber mailed: to a ‘Bank)
[844]wi? {4 ow tS ‘ i “ ae 1s ae
[845]23 Bea L eS OO a oa moe toly ahh wa
[846]PREVIOUS: FEDERAL CIVILIAN SERVICE |
[848]{Ep House of RepresentativesOfice of 22
[850]. maa ‘Separation date of last service @.
[852]Ho yes co Ll gee Be
[853]4 ‘Other Feder. al (Departments (including $ Senate and. Apéhitect)
[854]vo * Agéney’ Mayr aA Gordes lyte aha eda re Se
[855]( Name (if different £ fre om a present signature). _
[856]‘While eniployed as dbove Iwas covered by: : TR ay Ik yar toe ce 8
[858]Federal Employees’ Health Insurance: » pbivonas'e Ey not‘énvolled: fal eteladed. AOR: vee sic
[859]Federal | Employees’ Life Insurance: = optional oO regular; waived; = excluded,
[861]ELECTION OF RETIREMENT COVERAGE
[863]; Covert age SRhder the provisions ‘of the Civil Serviée Retirement Aki ig ‘étended to einployées Of the House
[865]of Representatives on a voluntary basis. Once you have. elected this coverage, and retirement deductions
[867]hi have been, withheld, such, deductions. ‘cannot, be. discontinued SO: Jong as you: are. continuously, employed
[869]nder t the. Act.
[871]ene Je Sey pe
[872]wy . ae er Cree
[874]YES
[876]I elect coverage under the: provisions of the: Civil Service Retirement Act and request. that: ‘deduc-_ 7 oe
[878]tions begin at the earliest possible date. (If you have had previous Fedéral: or: Military, Service, ©
[880]please submit dates, Agencies and Military Serial Number on a separate sheet. )s S No
[881]I do not wish to elect coverage under the Retirement Act at thistime. = = - ee |
[883](Note: Legislative employees é are enot covered by the _— Security Act. 7
[885]O ou. (Over) _ 7 wn! |
[890]Distriet of Columbia oe a penne a a ee SS:
[892]I do solemnly swear (or affirm) —_ oe
[893](1) That 1a Tama citizen of the United States.:.
[894]£] if.in the service on the date.of enactment of the latest Genera] Government, Matters
[895]; Appropriation Act, and being. eligible for citizenship, I had theretofore filed a declara-
[896]‘t. . tion of intention to become a citizen ; ; 7 -
[897]— “a I owe allegiance to the United States;
[898]*{] Iam an alien.from Poland or the Baltic countries lawfully admitted to. thé United States
[899]for permanent residence; ‘
[900](] Tama citizen of the Republic’ of the Philippines ;
[902]Cd Iam a national of a country allied with the United States i in the current defense effort ;
[904]x
[906]~ (2) That my aiceptance and jiolding of office or employment with the U.S. House of Representatives
[907]does not or (if this affidavit is executed by me prior to my acceptance of such office or employment) will
[908]not constitute a violation of the first section of the A Act of August 9, 1955 > U.S.C. 7311), which reads as
[911]No person shall accept or hold office: or -eiriployment in 1 the. Government of. the United States or any agency: thereof,
[912]_ including wholly owned Government corporations, who—
[913]- (1) ‘advocates the overthrow of our constitutiorial form of government in the United States;
[914](2) is a member of an organization that advocates the overthrow of our constitutional form of government i in the
[915]United States, knowing that such’ ‘organization so advocates;
[916](3) participates in any strike or asserts the right to strike against the Government of the United States or such
[917]agency; or
[918](4) is a member of an organization of Government employees that asserts the right to strike against the Govern-
[919]ment of the United States or such agencies, kriowing that such organization asserts such right; ; .
[921]owe a ns ao Pats
[923](3) That I Oam receiving a pension, annuity, or retired. pay from. the United. States
[925]RY am not
[926]Government (if SO,. please; furnish source.and, claim number) ; Ro
[928]. eos rn cote woe .
[930]et ee i ine cen ae an ee A Salen in Ren EERRRRRRE PURER ERROR
[932](Name:and: loéation of administering agency) .
[934](Claim number)
[936]A. That. this. Payroll Information Form and Personnel Affidavit is complete, true, and correct.
[938]. “BY ‘That’ T will support and defena the Constitution: of the United States against alle enemies, foreign
[939]und domestic; that I will bear true faith and allegiance to the same; that I take this obligation, freely,
[940]without any mental reservation or purpose of evasion; and that I will well and | faithfully discharge the
[941]duties of the office on which I am about to enter; So helpwieé-G ee : aan
[943]om fea. ~
[944]( U.S. GOVERNMENT PRINTING orrice 16—-82058-1 _
[947]GS. House of Representatibes
[948]. OFFICE OF THE CLERK
[950]IMPORTANT NOTICE TO EMPLOYEE
[952]Newly employed personnel must execute the attached combined PAYROLL INFORMATION FORM
[953]and PERSONNEL AFFIDAVIT properly and submit them to the Office of Finance, where a Notary Public
[954]is cn duty te perferm this service without charge. DO NOT SIGN PERSONNEL AFFIDAVIT UNTIL BEFORE
[955]A NOTARY.
[957]Currently employed personnel wishing to make changes in their records need only complete the perti-
[958]nent section of the PAYROLL INFORMATION FORM, indicate their employing office, and affix their signa-
[959]ture. Please be certain that information is legible enough for the Finance Office to identify the individual
[960]making the change.
[962]DETACH AND RETAIN THIS NOTICE
[964]. Salary payments are made by check monthly and mailed to the address designated on the Payroll
[965]Information Form. Checks are disbursed from the Office of Finance to normally reach the addressee on the
[966]last working day of each month.
[968]For additional information, contact the Office of Finance, 263 Cannon Office Building, Telephone
[969]Extension 56515 or 57064.
[971]EMPLOYEE BENEFITS
[973]RETIREMENT: An employee of the House of Representatives is eligible to join the Federal Civil
[974]Service Retirement System. Participation is voluntary, and action to elect retirement coverage may be
[975]initiated at any time by completing the appropriate section of the Payroll Information Form. Once an
[977]election is filed and the normal deduction of 74% percent of the gross salary commences, the.employee-
[978]eannot discontinue deductions so long as he is continuously employed. (Note: Legislative employees.are .
[980]not covered by the Social] Security Act.)
[982]LIFE INSURANCE: An employee is automatically covered under the Federal Employees’ Group |
[983]Life Insurance Act unless he waives or subsequently cancels such coverage by filing the required waiver .
[985]form with the Office of Finance. The insurance coverage is $10,000; or an amount equal to the gross annual
[986]salary, rounded to the next higher thousand dollars (if the salary is not a multiple of a thousand dollars),
[987]plus an additional two thousand dollars ; whichever is the greater. Additional optional insurance coverage
[988]in the amount of $10,000 is also available.
[990]HEALTH BENEFITS: The Federal Employees’ Health Benefits Program is available on a voluntary
[991]basis with costs partly financed by the Government. Within 31 days after the effective date of appointment,
[993]' every employee must register to enroll in a plan or not to enroll. Future opportunities to enroll or tochange . ~
[994]the type of enrollment are shown in the enclosed pamphlet. Also enclosed i is the necessary registration form, . -
[996]Standard Form 2809.
[998]_ US. SAVINGS BONDS: Monthly deductions for bonds in regular bond denominations may be
[999]authorized. Authorization cards are available in the Finance Office.
[1001]WORK INJURY BENEFITS: An employee injured or incurring disease as a result of performance
[1002]of duty is entitled to medical care and monetary benefits under the provisions of the Federal Employees’
[1003]Compensation Act. In instances where such injury or disease is fatal, the employee’s family is entitled to
[1004]monetary benefits. The Compensation Act is administered by the Bureau of Employees’ Compensation,
[1005]U.S. Department of Labor. Forms for filing notices of injury and claims for compensation a are available
[1006]in the Office of Finance or from any Postmaster. ©
[1008]UNEMPLOYMENT COMPENSATION: An employee may under certain circumstances be entitled
[1009]to unemployment compensation if discharged or otherwise separated from his employment. The com-
[1010]pensation is usually payable by the State (including the District of Columbia) in which the employee had
[1011]his last service. However, a claim for benefits may be filed in the local office nearest the employee’s
[1013]residence. If an employee is discharged for misconduct, quits voluntarily without good cause, or refuses a.
[1015]suitable job without good cause, then there is a period of disqualification which varies from State to State.
[1016]The amount of payments and period of time payable also varies from State to State.
[1018]16—82058-1
[1020]W 88326 et re __.
[1022]Wi:37243290 Page 12
[1025]a“
[1027]MEMORANDUM
[1029]TO: Thomas Howarth, Budget Officer
[1030]Elizabeth Berning, Chief Clerk
[1032]FROM: I. Charles Mathews, Special Counsel
[1033]DATE: December 19, 1977
[1035]RE: Ms. Wendy Collins
[1037]Please be advised that Ms. Wendy Collins has
[1038]accepted the position of Senior Attorney Researcher with
[1039]the Select Committee on ASSasSsinations. Her effective
[1040]starting date will be December 29, 1977 and her
[1041]starting salary will be $18,000.00.
[1042]| Your full cooperation will be appreciated in
[1044]| familiarizing her with staff procedures and welcoming
[1046]her aboard.
[1048]: ICM: 31
[1050]| NW 88326 ee _
[1051]| Docid:32243290 Page 13 : re
[1053]|
[1055]W 88326
[1057]MEMORANDUM.
[1059]TO: ALL STAFF
[1060]RE: Payroll certification
[1062]‘The Regulations and Accountin Procedures for Allowances sand ae
[1064]Expenses of Committees,.Members and Employees of the U.S. House of
[1066]"Representatives require that, among other things, the Committee's
[1067]monthly payroll certification include the relationship, if any, of =~
[1068]each employee to any current Member of ‘Congress. This certification —
[1070]is signed monthly by our Chairman.
[1072]The foi lowing are the relationships to be included in the =
[1073]certification: . . .
[1075]father oe 2 nephew - ae _ ‘then anctaw
[1077]; first cousin re -
[1079]- Please ‘complete the appropriate portion below, sign and’ date
[1080]this form, which will then become a part of your permanent personnel .
[1082]file. If this status. changes, you must notify 1 the: Committee's Budget
[1084]_ Office immediately of the change. — | | 7 we
[1085]EFT am not related to any current (95th Congress) Member of F Congress.
[1087]| a I am related to a current (95th Congress) Member of Congress. i
[1089](Please specify. )
[1091]Date
[1093]29 4 De?
[1095]mother ee ngece . - gister-in-Taw .
[1096]son oo ; - husband 5 si Stepfather - |
[1098]- daughter —. - . Wife ~ . . * gtepmother
[1099]brother = father-in-law =~ ~—s stepbrother
[1101]sister © - ,. mother-in-law ~ -- stepsister
[1103]uncle a os ' son-in-law =  ~.—---—sChal f-brother ne
[1104]aunt mo, a __, daughter-in-law oO half-sister Ss
[1106]i:37243290 Page 14
[1108]eel