SECTION 2: GENERAL INFORMATION

PRINT ALL INFORMATION www.lasersonline.org

Designation of Beneficiary

P.O. Box 44213, Baton Rouge, LA 70804-4213 225.922.0600 · Toll-Free 1.800.256.3000

Fax 225.935.2856

Form 01-06 R102018

Today's DateLast NameMiddle NameMember's First Name

IMPORTANT: Complete the entire form. Follow the specific instructions for each section. All dates should be in MM/DD/YYYY format.

SECTION 1: MEMBER'S INFORMATION

Zip CodeStateCityMember's Mailing Address

Daytime Area Code/Phone Number Member's Birth DateEvening Area Code/Phone Number Email Address

01-06 R102018 CONTINUE ON NEXT PAGE ERBER14 Page 1 of 3

This designation supersedes all prior designations. You must include ALL beneficiaries that you wish to designate. If percentages are not provided, any amounts payable will be divided equally among all beneficiaries. Primary and contingent beneficiaries must separately total 100%. The number of primary or contingent beneficiaries that you may name is not limited (attach an additional sheet if necessary). "Contingent" beneficiaries are eligible for payment only if all primary beneficiaries die before the member does. If you are not the member, you must submit a Certified copy of a "Power of Attorney" or other legal documents with this form. A COPY OF THE SOCIAL SECURITY CARD AND BIRTH CERTIFICATE FOR EACH BENEFICIARY IS REQUIRED.

SECTION 3: ACTIVE MEMBER BENEFICIARY

Birth Date Percentage Social Security Number

Female

Social Security Number

Male

Social Security Number

Female

MalePercentageBirth DateRelation, Trust, EstatePrimary Beneficiary's Name

Primary Beneficiary's Name Relation, Trust, Estate Birth Date Percentage

Female

Male Social Security Number

Social Security Number

Female

MalePercentageBirth DateRelation, Trust, EstatePrimary Beneficiary's Name

PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

Complete this section if you are a non-retired member of LASERS. Named beneficiaries will receive a lump sum of any employee contributions not directed by statute. Do not complete this section if you are completing paperwork to retire and are naming your retirement beneficiaries.

Primary Beneficiary's Name Relation, Trust, Estate

SECTION 4: RETIREMENT BENEFIT BENEFICIARY

01-06 R102018 CONTINUE ON NEXT PAGE ERBER14 Page 2 of 3

Relation, Trust, Estate Social Security Number

Female

MalePercentageBirth DateContingent Beneficiary's Name (optional)

CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

Social Security Number

Female

MalePercentageBirth DateRelation, Trust, EstateContingent Beneficiary's Name (optional)

Social Security Number

Primary Beneficiary's Name Relation, Trust, Estate Birth Date Percentage Male

Female

Social Security Number

This section should only be completed if you are submitting a Retirement, Retirement with IBO, DROP, or Disability Retirement application, or if you are updating your current Maximum or Option 1 monthly retirement beneficiary(ies).

Primary Beneficiary's Name

Primary Beneficiary's Name

Primary Beneficiary's Name

Relation, Trust, Estate

Relation, Trust, Estate

Relation, Trust, Estate

Birth Date

Birth Date

Birth Date

Percentage

Percentage

Percentage

Male

Male

Male

Female

Female

Female

Social Security Number

Social Security Number

Social Security Number

CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

Contingent Beneficiary's Name (optional)

Contingent Beneficiary's Name (optional)

Relation, Trust, Estate

Relation, Trust, Estate

Birth Date

Birth Date

Percentage

Percentage

Male

Male

Female

Female

Social Security Number

Social Security Number

SECTION 5: DROP OR IBO ACCOUNT BENEFICIARY This section should only be completed if you are naming or updating your DROP or IBO account beneficiary(ies).

PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

Primary Beneficiary's Name Relation, Trust, Estate Birth Date Percentage

Female

Male Social Security Number

Primary Beneficiary's Name Relation, Trust, Estate Birth Date Percentage Male

Female

Social Security Number

Social Security Number

01-06 R102018 RETAIN A COPY FOR YOUR RECORDS ERBER14 Page 3 of 3

Member's Signature Date

I hereby request that my beneficiary(ies) be designated as above. I understand that the beneficiary(ies) designated on this form will receive my contributions to the retirement system, unless I have qualifying survivors (spouse, children) entitled to a monthly survivor's benefit.

Primary Beneficiary's Name Relation, Trust, Estate Birth Date Percentage

Female

Male Social Security Number

Primary Beneficiary's Name Relation, Trust, Estate Birth Date Percentage

Female

Male Social Security Number

CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

Contingent Beneficiary's Name (optional) Relation, Trust, Estate Birth Date Percentage

Female

Male Social Security Number

Social Security Number

Female

MalePercentageBirth DateRelation, Trust, EstateContingent Beneficiary's Name (optional)

SECTION 6: MEMBER SIGNATURE

SECTION 2: GENERAL INFORMATION

 

PRINT ALL INFORMATION

www.lasersonline.org

Designation of Beneficiary

P.O. Box 44213,  Baton Rouge, LA  70804-4213 

225.922.0600  ·  Toll-Free 1.800.256.3000

Fax 225.935.2856

Form 01-06

R102018

IMPORTANT:  Complete the entire form. Follow the specific instructions for each section. All dates should be in MM/DD/YYYY format.

SECTION 1: MEMBER'S INFORMATION

 

01-06 R102018                                                              CONTINUE ON NEXT PAGE                                                ERBER14  Page 1 of 3

This designation supersedes all prior designations.  You must include ALL beneficiaries that you wish to designate.  If percentages are not provided, any amounts payable will be divided equally among all beneficiaries.  Primary and contingent beneficiaries must separately total 100%.  The number of primary or contingent beneficiaries that you may name is not limited (attach an additional sheet if necessary). "Contingent" beneficiaries are eligible for payment only if all primary beneficiaries die before the member does. If you are not the member, you must submit a Certified copy of a "Power of Attorney" or other legal documents with this form.  A COPY OF THE SOCIAL SECURITY CARD AND BIRTH CERTIFICATE FOR EACH BENEFICIARY  IS REQUIRED.

SECTION 3: ACTIVE MEMBER BENEFICIARY

PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

Complete this section if you are a non-retired member of LASERS. Named beneficiaries will receive a lump sum of any employee contributions not directed by statute. Do not complete this section if you are completing paperwork to retire and are naming your retirement beneficiaries.

SECTION 4: RETIREMENT BENEFIT BENEFICIARY

 

01-06 R102018                                                                CONTINUE ON NEXT PAGE                                       ERBER14 Page 2 of 3

CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

This section should only be completed if you are submitting a Retirement, Retirement with IBO, DROP, or Disability Retirement application, or if you are updating your current Maximum or Option 1 monthly retirement beneficiary(ies).

CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

SECTION 5: DROP OR IBO ACCOUNT BENEFICIARY

This section should only be completed if you are naming or updating your DROP or IBO account beneficiary(ies).

PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

 

01-06 R102018                                                    RETAIN A COPY FOR YOUR RECORDS                                   ERBER14 Page 3 of 3

I hereby request that my beneficiary(ies) be designated as above.  I understand that the beneficiary(ies) designated on this form will receive my

contributions to the retirement system, unless I have qualifying survivors (spouse, children) entitled to a monthly survivor's benefit.

CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%

SECTION 6: MEMBER SIGNATURE

8.0.1291.1.339988.308172

bar_code: SOLARISCURRENTDATE: SOLARISMEMBERLASTNAME: SOLARISMEMBERMIDDLENAME: SOLARISMEMBERFIRSTNAME: ZipCode: State: City: mailing_address: eve_phone: birth_date: email: SSNBARCODE: ssn: : SOLARISMEMBERSSN: beneficiary: relation: ResetButton1: TextField1: DateTimeField1: