◆ SpookStack

Pot MIO CONCCANING DEPENDENT CHILDE _OF [LIE DECEASED Pobat ous Pat ve eg tates a CH ag The DOC ASE WHO WERE UPIODCR AGE 14 AT THE te ( 1O8 FR) DEATH. IICLUOE LEGALLY ADOPTED Peo a oe dy ABER il pant b LM, ARID INGICAFE AFIC@ THeiR BLAMES FIA THLY ARE AUS | - TLREGIPAATE, OR STEP CHI OZEN. Ratha o SQ MY Ue a a OPAC FD ARID 22 WHOIS APULL TIME CRUST I A Re COGMIZED ECUCATIONAL INSTIUTION, WRHE THE WORD TUR aD Sin PAL CH POSE (A STUDS MNOS LAST DitIHOAY FALLS GUNG A SCHOOL YEAR (SEPTEMBER 1 THROUCH JUNE 30) 1S DEEMED RT TOOT AGE 22 UE THE canbe JUL TPO WER, POU blot SUCH A CiliiD, DY SURE TO SHOW HIS ACTUAL UATE OF BIRTH] Ire ier ALLO oy Ute yA Cit Ovid 18 we BECAME DISAELTO TLFO CT AGE 1d atl WitO, BECAUSE OF THE DISABILITY, 15 INCAPABLE OF SCLF-SUPPORT, SAE The WORD Cis acto ArTiR OUCH CHLO'S Tiare AND ATIACH A SEPARATE SHILED Givit;G FULL PASTICULARS ALOUT THE DISABILITY. DID CHILO RECEIVE — MORE THAN ONE- HALF HIS SUPPORE FROM DiCFASEO? DATE OF CIRTH CMewt) (fay) € Veurs NAME AND ADDRLSS OF PERSON WHO HOW HAS THE FULL AME OF CHILD CHILD AND HIS [OR HER) RELATIONSHIP TO THE CHILD 2 IF ALY STEPCHiLD OR HILGHIMATE CHILD LISTEQ ABOVE WAS NOT LIVING WITH THE DECEASED AT THE TIME OF HIS {OR HER) DEATH, GIVE NAME OF CHILD ARO EXPLAIN BRIEFLY WHY THEY WERE LIVING APART. 4. 1S THERE AN UNSORN CHILO OF THE DECEASED? Cs (K] no 3. ¥ A GUARDIAN HAS NOT BEEN APPOINTED, WAL ONE BE APPOINTED? CL] ves ([[] xo F, In ORMATION CONCERNING NON-DEPENDENT CHILDREN AND OTHER RELATIVES OF THE DECEASED 1 ee me, 1. ST lOW THE Name, AGE, EIC., OF [HE DECEASED 'S WICOW OR WIDOWER. 4 IFA GUAROIAN Has BECH x POLNTED bY THE COURT FOR ANY GF THE CHILDREN LISTED ABOVE, GIVE GUARIVAN'S NAME AND ADDRESS. MAME ADDRESS ee en 2. 3F NO WIDOW OR WIDOWER SURVIVES, LIST ALL CHILDREN OF IHE DECEASED NOT NAMED IN ITEM E, AND THE DESCENDANTS OF ANY DECEASED CHHD OR CHILDREN, 7 3. UF THESE ARE NO CHILDREN OR OLSCENDANTS OF DECEAS(O CHILDREN, LIST THE OECEASED’S PARENTS (IF LIVING), BROTHERS, AND SISTERS, AND DESCENDANTS OF HERE ARE NO SURVIVORS WITHA THE DEGREES INDICATED IN 1, 2, AND 1, LIST THE HEIRS WHO CAN INHERIT FROM THE DECEASED, RELATIONSHIP TO CECEASED ADDRESS (see attached) | G._ CERTIFICATION WAKNONG.-- Any intentional false state- Pherchy certify that all statements made in this application are true to the ment ia this applicauon or willful: misvepre- best of iny knowledge, information, and dbelicf, and chat no evidence necessary sentation relative thereto is a violation of the to a sewement of this claim is suppressed of withheld. law punishable by a fine of not more than | —--. --—---—— .--——-—-- ,----_—_- $10,600 or imprisoninenc of not more than § | SIGNATURE OF APPLICANT VA . years, or both. (18 U.S.C. 1001.) > ke, C22 hsanr Clyde A. Talsop’ (2 chi. NOTICE nunale Ano sitet C. 0 Rigss &tional Bank Forward application tu the Bureau of Re- [Personal Trust Div. ’ P.O, Box 11g tircment, Ensurance, aud Occupational Health, |. —-———- --—--—— United States Civil) Service Coinmission, | SHY. STATE ANO LP CODE Washington, I0.C. 20465. Washington, D.C. 29013 Attn: Mr. Brewer # INFORMATION FOR THE APPLICAN IF ASSISTANCE IS NEEDED EVIDENCE REQUIRED . . : . ae If you need assistance in completing this appfication, con- There muse be submitted with this application a certified tace the personnel! office of the department oc agency in which copy of the public record showing the death of the employee the deceased was employed, the nearest tegional office of the or wunuitant, Failure to subsite such death certificate will United Stares Civil Service Commission, or the Bureau of defy setdoument of chain. Rerirement, Insurance, and Occupativaal Health, United States Civil Service Contuission, Washington, D.C, 20415. Any other necessary evidgace not of record in the United _— ; States Cisil Scevice Cotumission will he requested altec re- tINAL DETERMINATIONS coipt of this application, . Upon receipt of this application, the United Scates Civil Service Commission will determine what benefus, i any, ace payable, the amount of such benefits, and co whom they are payable. ‘Fhe Cominissioa will inform the applicant of the i final determination, De te mrs ee ee es ee Se a Ge COVERR MONT PRINTING OFFICE $870 OF ~-392-4597 (248) ao CD ee et Se eS i. for re roe Se Ne een ran ue etc carne TR ni CRT ae ate, Spee pane o