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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: