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FEBDEKAL BUREAU OF INVESTIGATION fa Reply, louse Refc tw File No - ‘1 1 1 eel Peg, abr I net p I the pedo the desu grat do beneficiary of any Special Agent of the FB] wh. has previously , : from an cause except Selicdestruction while employed as a Special Agent, ] aim for- ra it (by Check - Money Order) toe num of $10, payable tu S.A.F., to be anctuded om said fund. Payment will be - : Pea te ent bas beet ao member of the fund fora continuous pened of two yeurs. [tis Pot oge on benderot hetewath as a voluntary, gratultous contribulion to said fund which | understand wooo tRe 8 OD) Nat yg fading rothe GPP will appoint a committee which shall conmider ali matters pertaining to the acquisition, safe Reese yt way - oy F Sts fund, which committee will recommend approptiate action to the Director in pertinent matters, the Agsastap 7 ‘aie Sovd the Acconmistratave Division of the FRI shall receive all contributions ond account for same to the Tope fo TR rn teeth oc touny special Agent who ig a member of said tund the appointed committee will consider the case Bebo cube ope . G@atisn to the Urrecter @s to its conclusions, Appropriate inatructions will then be iagued tao the A sa#ist- dat love cto b tte Vanunastrative tavisiun, directing him to pay to the designated beneficiary the sum of $10,000, The lHability ord thee tard shot: > ander any icurbiancee enceed the amount of monies in the fund at the time any Hability aheall sccur. EXECUTE IN DUPLICATE AND SUBMIT BOTH COPIES TO THE BUREAU Official Bureau Name (please Lype or print) Office of Assignment (or SOG Division) xx dd. Edgar Hoover | 1-28-64 The following perwan 16 designated us ny beneficiary for Special Agente Insurance Fund: Seat of Government, DD) S ane (primary beneficiary; use given first name if female? estate Relationship Address | Nae - Veuntingent b bere fe lary, if desired : use given firat name if female) Relationship Addrese ee The following person ia designated as my beneficiary under the Chas. S. Ross Fund providing $1500 death benefit to deneficiary uf agents killed in the line of duty, other than travel accidents. Name (primary beneficiury; uae given firat name if female) Relationship a 7 = | Address Addreas Very truly yours, ector eR erie es Rep ae ye an Ne RR RE Se ETRE IN ET TT ETT SMe SE eet