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( CL UNITED STATES DEPARTMENT OF JUSTICE FEDERAL BUREAU OF INVESTIGATION In Reply, Please Refer to WASHINGTON 25,D.G File No. - Durector Federal Sureygn of !' vestigation United States Department of Justice Washington, D.C. AE: Bd — (Type or print plainly) Dear Sir: For inciuaion in the fund to be paid to the desiqnated beneficigry of any Special Agent of the FBI who has previously contributed to this fund and who dies from any cause except self-destruction while employed as a Special Agent, lam forwatding hetewtlth (by CHECK - MONEY ORDER) the sum of $10, poyable te the Assistant Director, Administrative Diviaion, FBI, to be included In satd fund, Payment will be made for death by self-destruction after the Agent has been a member of the fund fcr a continuous period of two years. It is understood and agreed that the sum tendered herewith ls a voluntary, gratuitous contribution te said fund which |] understand is to be administered in the following manner. The Direcicr of the FBI will appoint a committee which shall consider all matters pertaining to the acquisition, wate keeping and azperding of agid fund, which committees will tecommend approptiate action to the Director in pertinent matters. The Assistant Director of the Adminiatrative Division of the FBI shall receive ai] contributions and account for same to :fe Director. pon the death of any Special Agent who is a member of said fund the appointed committee will consider the case and submit a recommendation to the Director ae to ite conclusions. Appropriate instructiona will then be issued to the Assistant Director of the Administrative Division, directing him to pay to the designated benaficiary the sum of $10,000. The Malility of the fund ahall not under any circumstances exceed the amount of monies in the fund at the time any Hability * ahall occur. The to licwing person is designated as my beneficiary for FBI Agenta’ Inaurance Fund: E Nome ~ Relationship Date i. Address a i es The foliswing person is designated as my beneficiary under the Chas, &. Ross Fund providing $1500 death benefit to p E \ Seneticiar, uf agents killed in the line of duty. . h —__ Name Relotionship Date Estate Address ocr ime be od | Very truly yours, . . Sqoarmen lt Fe Stor fe Oe pumped