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( ( UNITED STATES DEPARTMENT OF JUS7ICE FEDERAL BUREAU OF INVESTIGATION In Reply, Please Cucer to File ie. Were 1 te be pald to the designuted heneficiary of a¢ny Spectal Agent of the [HL whe has Bitvisualiy hod ard, dies Grom ony caure except self-destruction whaiet employed as a Special Agent, | am tor- ‘ Tioga? ay Check - Money Order) the. sum of $20, poyable to GALI. to be included an said fund, Payment wii! | Pederttsctecn utter the Agent has been aoimember ot the fund fora continu: ar Period of two years, [tro ba dbat che tum tendered bhorewith as oa voluntary, gratulicus coniulkutien ta eu.d fund which | understand Hat: Me tee Po tuawing munner. + Tose -oouf the F bl will appoint a committee which shall congider al] matters pertoining to the Ocquisition, safe Keer ty at ® ua fo sant fund, which commiftee will racommend appropriate artion to the Director in pertinent matiers, oan . a eoogt toe Aajnantetratiwe Otvigion ot she Fist shail receive all contributions 4 account for same to the ‘ cot thoc horny Special Agent who is 4 member of said fund the oppoamted comm .ottee will consider the can. station ' the Qirecior a8 fo its conclusions. Appropriate ineiructions will teen be 1seued te the Awsist- wnistrative Givision, curecting him to pay to the designated beneficiary the sur. of $10,000, The lagbility tone | auder any cifcumelances exceed the amount o! monies in the tund at the tine any liability shall oecur, “UTE IN DUPLICATE AND SUBMIT BOTH COPIES TO THE BUREAU aa! is reug Wa. viewge Lype or print) Date Office of Aseignment (or SOG Division) ri J, adgar ieover 2 Director _ “) ofdlowing perso: +e designated as my beneficiary for Special Agents Insurance Fund: Nau ne Upr. te. bene” 2: yr use. given first name if female) Relatronship _ _ ..#state ine woe COosorgent ber c “ary, if desired: use given first name if female) Relationship yates oo de a the abo -listed beneficiuries aa the beneficiary and contingent beneficiary respectively of the ine - ake eeftl? SoSesn (7D No | If not, the entire following portion must be executed, Ti: i lowing © -s0n is des gnated as my beneficiary under the Chas. S. Roas Fund providing #1500 death benefit to heneficiut: | agents kifled in the line of duty, other thon travel accidents, Name {pr - y benefic: z+; use given firet name if female} Relationship Vtimss Same (conti: gent be . Lcvary, if desired: use given firet name if female! Relationship Auns = a Very truly yours, a — Directpr, FsI Special Agent