SECRET (When Filled In)
CERTIFICATION OF SEPARATING EMPLOYEE
Name (Last-First-Middle)
COLEMAN, BIRCH D.
MEMORANDUM FOR THE RECORD - ATTACH TO OFFICIAL PERSONNEL FOLDER
I hereby acknowledge the receipt of the following forms and/or information concerning my separation from CIA as indicated by check mark:
1. Standard Form 8 (Notice to Federal Employee about Unemployment Compensation).
2. Standard Form 55 (Notice of Conversion Privilege, Federal Employees' Group Life Insurance).
3. Standard Form 56 (Agency Certification of Insurance Status, Federal Employees' Group Life Insurance Act of 1954).
4. Standard Form 2802 (Application for Refund of Retirement Deductions).
5. Form 2555 (Authorization for Disposition of Paycheck).
6. Applicable to returnee (resignee from overseas assignment).
I have been advised of my right to have a medical examination before my separation from this Agency and of the importance of such a medical check to my health and well-being.
□ Appointment arranged with Office of Medical Services.
□ Appointment for Office of Medical Services examination declined.
7. I have been informed of "conflict of interest" policy of the Agency and foresee no problems in this regard concerning my new employment.
8. Form 71 (Application for Leave).
9. CSC Pamphlet 51 (Re-employment Rights of Federal Employees Performing Armed Forces Duty).
10. Instructions for returning to duty from Extended Leave or Active Military Service.
Signature of employee: Birch D. Coleman
Date Signed: February 27, 1970
Address (City, State, ZIP Code): 5 West 86th Street, New York, NY 10024
Correspondence: □ Overt □ Covert
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