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UNITED STATES DEPARTMENT OF JUSTICE _ FEDERAL BUREAU OF INVESTIGATION In Reply, Please Refer to File No. - December 6, 1965 Directs: Feders, Ruregu ol Inveatigation United States Department of Tustice Wastington, [7 eh 4at Dear Sir: Pordnea.ca moun the Jond to be paid to the desiqnated beneficiary of any Special Agent of ihe FBI who has previously erie ted ta tas fund and whe dies from any cause except sél{-destruction while employed as a Special Agent, Iam for wardl- ; herewitl (by Check - Money Order) the sum of $10, payable ta S.A-1.F., to be inciuded in said fund. Payment will be made tor death cy seliedestrue tron alte: the Agent has been a member of the fund fora continuous period of two years. Ii is gnderst od and aiteed that the sum tendered herewith ts a voluntary, gratuitous contribution to said fund which | understand is ty oP Admanic: ted ain the following munner, The Director of the FBI will appoint a committee which shall consider all matters pertaining to the acquisition, sale tng Gad |x; Fig of said fund, which commitise will recommend appiopiiaie aciion io ihe Director in pertinent matters, . Assistant “nector of the Administrative Division of the FBI shel) receive all contributions and account for a@ame to the stot, Upor the dedth of amy Special Agent who is a member of aaid fund the appointed committee will consider the case and submit a recommendation to the Director a to ita conclusions, Appfopricte instructions will then be igaued te the Asmist- ant Directur af the Administrative Division, directing him to pay to the designated beneficiary the sum of $10,000, The liability of the fund sha.! zc' under any cifcumstances exceed the amount of monies in the fund ot the time any liability #hall occur. EXECUTE iN DUPLICATE AND SUBMIT BOTH COPIES TO THE BUREAU Official Bureau Name (please type or print? Office of Assignment for SOG Division) oA J. Edgar Hoover Office of Director The following person is designated as my beneficiary for Special Agents Insurance Fund: Name (primary beneficiary; use given firat name if female} —____—_Betate Addregs Relationship Name (contingent beneficiary, if desired; uee given first name if female! Relationship Address *s you desire iv de ghaie ihe above-iisied beneficiaries ae the beneficiary and contingent beneficiary reapectively of the Chas. S. Ross Fund a+ well? (7] Yea C1 No If not, the entire following portion must be executed. The following person ia designated as my beneficiary under the Chas. 8. Roas Fund providing $1500 death benefit to beneficiary of agents killed in the line of duty, other than travel aceldents. Relationship Name (primary benefic:ury; use given firat name if female) __ Estate Address mT Te Name (contingent beneficiary, if desired, use given first name if female! | Relationship Address Very truly yours, 8-ecd a yy eg PR SE RMD er ae : ; :