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26080842
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Enrollment Forms
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26080842
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Enrollment Forms
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Records of the First Lady's Office (Clinton Administration)
Margaret “Maggie” Williams' Subject Files
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42-t-2194630-20130359S-Seg2-038-011-2015
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-make new hanging
Thift Savings Plan
file called
Open Season
-May 15 - July 31
"enrollment form"
- -new employees must
Dianes
sit through one apen
Season before they
are eligible to enroll
- next open season-Nov.1983
Health Benefits
- next Open Season
November 1993
(Michelle Joy) X 5890
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Enrollment information
& Plan Comparison Chart
1992 Open Season for
Federal civilian employees
FEHB
Federal Employees
Health Benefits Program
What's inside:
Enrollment information
1
Plan comparison
8
Plan Comparison Chart
14
Fee-for-service plans
14
Prepaid plans
16
United States
Retirement and Insurance Group
Office of
1900 E Street, NW
RI 70-1
Personnel
Washington, DC 20415-0001
Rev. November 1992
Management
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
UNICOR FEDERAL PRISON INDUSTRIES INC.
LEAVENWORTH KANSAS
THRIFT SAVINGS PLAN
TSP-1
ELECTION FORM
Use this form to:
Start or change your contributions to the Thrift Savings Plan (TSP)
Stop your contributions to the TSP
Indicate how you want your future contributions to be invested in the three TSP Funds
Before completing this form, please read the Summary of the Thrift Savings Plan for Federal Employees and the instructions on
the back of this form. Type or print all information. Return the completed form to your agency employing office. Do not
remove your copy. Your agency will return it to you after completing Section VII.
I.
1.
INFORMATION
Name (Last)
(First)
(Middle)
ABOUT YOU
2.
Street Address
City
State
Zip Code
3.
4. (
)
Social Security Number
Daytime Phone (Area Code and Number)
5.
6.
Date of Birth (Month/Day/Year)
Office Identification (Agency and Organization)
II.
Complete either Part A or Part B of this section.
AMOUNT OF
Part A. To contribute to your TSP account, enter
Part B. If you are a FERS employee who is not,
YOUR
either a whole percentage of your basic pay per
and will not be, contributing to your TSP account
CONTRIBUTIONS
pay period (Item 7) or a whole dollar amount per
at this time, but you are allocating your Agency
pay period (Item 8).
Automatic (1%) Contributions, check Item 9.
If you complete this section.
you must also complete
Section IV
7.
.0%
OR
8. $
.00
9.
(Noncontributing FERS)
III.
To stop your contributions to the TSP, check Item 10 and sign and date Items 15 and 16. If you are a
STOPPING YOUR
FERS employee, your Agency Automatic (1%) Contributions will continue. You must complete Section IV
CONTRIBUTIONS
to show how you want these contributions to be divided among the three TSP Funds.
Do not complete Section II.
10.
I want to stop contributing to my TSP account. I understand that my payroll deductions will stop
FERS employees must
at the end of the pay period in which my agency employing office accepts this form.
also complete Section IV
IV.
Show how you want future contributions to your account to be divided among the G, F, and C Funds.
ALLOCATING
Enter the percentage (in multiples of 5%) that you want invested in each Fund. Do not use dollar
CONTRIBUTIONS
amounts. The total of Items 11, 12, and 13 must equal 100% If you are a FERS employee, the
percentages that you choose will be applied to all contributions to your account, including Agency
You must also complete
Automatic (1%) Contributions and Agency Matching Contributions.
Section // or III
If you invest in either the F or C Fund, you must sign Item 14; otherwise, your form will be returned to
you unprocessed.
11. G Fund Government Securities Investment Fund
.0%
12. F Fund
Fixed Income Index Investment Fund
.0%
13. C Fund Common Stock Index Investment Fund
.0%
Total
100.0%
V.
I have chosen to invest in the F and/or C Fund. | understand that I am making this investment at my own
ACKNOWLEDGE-
risk. I also understand that I am not protected by. either the U.S. Government or the Federal Retirement
Thrift Investment Board against investment loss in the F or C Fund, and that neither the U.S. Govern-
MENT OF RISK
ment nor the Federal Retirement Thrift Investment Board guarantees a return on my investment.
Also sign Section VI
14.
Participant's Signature
VI.
You must sign Item 15 and date Item 16; otherwise, your form will be returned to you unprocessed.
SIGNATURE
15.
16.
Participant's Signature
Date Signed
VII.
17.
18.
19.
20.
FOR
Payroll Office Number
Agency Code
Effective Date
TSP SCD (Optional)
EMPLOYING
21.
22.
OFFICE USE
Signature of Employing Office Official
Acceptance Date
23.
24.
ONLY
New Eligibility Date if Item 10 Is Checked
Remarks
PART 1 - OFFICIAL PERSONNEL FOLDER-ORIGINAL
Form TSP-1 Revised 2/91
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Thrift Savinas Plan for Federal
Employees
TSP
at a
Glance
Thrift Savings Plan for
Federal Employees
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
CSRS Employees: The Next Move
Is up to you.
CSRS
Employees:
The
Next
INFORMATION
Move
C
Is Up
to You
*
*
*
*
The Thrift Savings Plan
for Federa Employees
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Loan Program
Federal Retirement Thrif:
Investment Board
Januar 1990
Thrift
Savings
Plan
Loan
Program
Federal Retirement
Thrift Investment Board
January 1990
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Contains Important Information in the TSP About
*
SUMMARY OF THE
*
THRIFT SAVINGS PLAN
*
FORFEDERAL EMPLOYEES
SEPTEMBER 1990
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Standard Form 2809
Children who lose FEHB coverage; and
Rev. August 1992
FAHR
Former spouses who are not eligible for FEHB under
Federal Employees
item 3 above.
Health Benefits Program
Form Approved.
OMB No. 3206 0160
Note: Former spouses and children of CSRS/FERS
Health Benefits
annuitants Do noi use this form. To obtain the
appropriate form. write to address shown in item 2 above.
Registration Form
Instructions for Completing SF 2809
Uses for Standard Form (SF) 2809
Type or Print Firmly
Use this form to:
PART A. You must complete this part.
Enroll in the FEHB Program; or
Item 1.
Give your last name, first name and middle initial.
Elect not to enroll in the FEHB Program (employees
Item 2.
Enter your Social Security Number. (See Privacy
only); or
Act Statement on Page 5.)
Change your FEHB enrollment from Self Only to Self and
Item 3.
Give your date of birth, using numbers to show the
Family and/or from your present plan or option to another
month. day and year
plan Of option because of an event described in the
Table on page 6: or
liem 4.
Enter your permanent home mailing address.
Change your FEHB onroilment from Self and Family to
Item 5.
Place an "X" in the appropriate box.
Self Only; or
Item 6.
Place an "X" in the box that signifies your current
Cancel your FEHB enrollment.
marital status (if you are separated but not
divorced, you are still married).
Who May Use SF 2809
Item 7.
Give your telephone number where you can be
reached during normal business hours. Be sure to
1. Employees eligible to enroll in or currently enrolled in the
include the area code.
FEHB Program. including temporary employees eligible
under 5 U.S.C. 8906a.
PART B. Complete this part to enroll or change your enroll-
2. Annuitants (other than CSRS/FERS annuitance eligible
ment in the FEHB Program. (If you are changing your
o enroll in or currently enrolled in the FERB Program,
enrollment, also complete PART C.)
including individuals receiving monthly compensation
Item 1.
Enter the plan name ann appropriate enrollment
nom in Office of Workers' Componsa Non registrars
0009 from he MOTA cover of the brochtine of the
plun you want to enroli in or change to the
ser the has plan option VOID are
Note: M/FERC annuitants Do not use this form.
during 190 whether ... at coursting in Sell Carly
To obtain the appropriate form, write 101
or Selt and Fan VA you are just changing from
on uption P.I. her multion from Sclf Only to Solf
Office of Personnel Management
allo Family hom well and Family to Sell Only.
Insurance Services Branch
enter the 00126 of your present plan and the new
P.O. Box 14172
unrollment code.
Washington, D.C. 20044
If the plan you want : : prepaid plan (CMP/HMO),
be sure you live #: plans enrollment area. If it is
3. Former spouses eligible to enroll in or hurrently one the
30 employee openization plan, Do GUID your and
in the FEHB Program under the Spense injuity he Y
ligible in in the den; you must be or become
similar statutes.
a mentho of I lan's sponsoring organization.
4. Individuals eligible for temporary continuation of noverage
Y CUII sign the :1 Pen authorize led intions from
under the FEHB Program, including:
your salary, annusly or : meensation to nover your
cost of the enfollmed you elect - this item. unless
Former employees (who separated com service);
you are required X make street payments to the
employing office
i
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
FEHB
HEALTH BENEFITS REGISTRATION FORM
Form Approved:
OMB No. 3206-0160
Federal Employees
Health Benefits Program
Complete Part A and Parts B, C,
Federal Employees Health Benefits Procerm
Type or Print Firmly.
D, and E as applicable.
Do not separate the copies Your employing office will certify the completed form a - return your copy to you.
Sign and date in Part F
PART A Fill in this part.
1. Name (Last, first, middle initial)
2. Social Security number
3. Date of birth (mo., day, yr.)
/
/
4. Your home mailing address (include ZIP code)
5. Sex
6. Are you now married?
Male
Female
Yes
No
7. Daytime telephone number
(
)
PART B Fill in this part if you wish to enroll or change your enrollment in the Federal Employees Health Benefits (FEHB) Program.
1. I elect to enroll in a health benefits plan as shown below. (Copy the information requested below from front cover of brochure of the plan you select.)
Name of plan
Enrollment
code
2a. Names of family members
2b. ZIP code
2c. Date of birth
2d. Sex
2e. Relationship
2f. Social Security number
(mo., day, yr.)
"code"
(See Instructions)
/
/
/
/
/
/
/ /
/
/
3a. Do you, your spouse or any other eligible family members have any group health insurance coverage other than
the FEHB plan in which you are now enrolling or enrolled?
No
Yes
Complete 3b
3b. Type of insurance
Medicare
Indicate part(s)
CHAMPUS
Other private (specify name)
No
Yes
PART C - Fill in this part, as well as PART B, to change enrollment.
1. Present Plan name
2. Present Plan
3. Number of event that
4. Date of event that permits
enrollment
permits change
change
code
(See Table of
(mo., day, yr.)
Permissable Changes)
/
/
PART D - Employees Only
PART E - CANCELLATION
Place an "X" in the box below if you wish NOT TO ENROLL in the FEHB
Place an "X" in the box below if you wish to CANCEL
Present Plan enrollment code
Program.
your enrollment.
I elect not to enroll in the Federal Employees Health Benefits Program.
I elect to cancel my enrollment in the Federal
Employees Health Benefits Program. I am currently
enrolled under the code shown at the right.
My signature in PART F certifies that I have read and understand the
My signature in PART F certifies that I have read the information in the instructions
information regarding this election.
regarding cancellation of enrollment and that I understand that I must meet the 5-year
requirement to qualify for FEHB coverage after retirement.
PART F - Fill in this part.
WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001.)
1. Your signature (Do not print)
2. Date
PART G To be completed by agency
1. Name and address of employing office
2. Date received in employing office
3. Effective date of action
4. SF 2811 report number
5. Payroll office number
6. Payroll contact and telephone number
(
)
7. Personnel contact and telephone number
(
)
8. Signature of authorized agency official
9. Phone number
(
)
Remarks
Office of Personnel Management
2809-119
Previous editions are
Standard Form 2809
FPM Supplement 890-1
NSN 7540-01-231-6227
Copy 1 OFFICIAL PERSONNEL FOLDER
not usable.
Rev. August 1992