MUST COMPLETE BACK OF FORM

MUNICIPAL POLICE EMPLOYEES’ RETIREMENT SYSTEM
MP-9 (01/13)
7722 OFFICE PARK BOULEVARD, SUITE 200
BATON ROUGE, LA 70809-7601
Telephone: (225) 929-7411 • Toll Free: (800) 443-4248 • Fax: (225) 929-6542
www.lampers.org
APPLICATION FOR INITIAL BENEFIT OPTION (IBO)
**Complete both sides of application
Name
Date of Birth
Social Security Number
Mailing Address, City, State, Zip Code
Single never married
Married. If your current status is married but your previous status was divorced, we must receive a copy of your divorce decree(s).
Divorced. If your current status is divorced, we must receive a copy of your divorce decree(s).
Last Date on Active Payroll
Effective Date of Retirement Benefits
Area Code and Telephone Number
____Male
____Female
Check one: Number of months for lump sum
______ 12 months ______ 24 months ______ 36 months Other: ______ months
SELECTION OF RETIREMENT PLAN OPTION – INDICATE CHOICE BY SIGNATURE
Maximum Plan - Pays largest monthly benefit retiree is eligible to receive but does not provide for a monthly benefit to be paid to a named
beneficiary after the retiree’s death; however, in the event the retiree dies before he/she receives in benefits an amount equal to his/her contributions,
the beneficiary or estate will be paid the difference in one lump sum payment. I hereby apply for retirement under the Maximum Plan. Spouse must
complete form MP-4A.
Signature:
Date:
Option 2 - Pays the retiree a monthly benefit that is reduced from the Maximum. Pays the same monthly benefit for life to the named retirement
beneficiary after the retiree’s death. The benefit is based on the ages of the retiree and his/her beneficiary. The beneficiary may not be
changed after retirement. I hereby apply for regular retirement under the Option 2 Plan.
Signature:
Date:
Option 2a (formerly 4-1) - Pays the retiree a monthly benefit that is reduced from the Maximum. Pays the same monthly benefit for life to the named
retirement beneficiary after the retiree’s death. However, if the named beneficiary predeceases the retiree, the benefit amount will convert to
the Maximum Plan and benefits will cease upon the death of the retiree. The benefit is based on the ages of the retiree and his/her beneficiary. The
retirement beneficiary may not be changed after retirement. I hereby apply for regular retirement under the Option 2a Plan.
Signature:
Date:
Option 3 - Pays the retiree a monthly benefit that is reduced from the Maximum. Pays 50% of the monthly benefit for life to the named retirement
beneficiary after the retiree’s death. The benefit is based on the ages of the retiree and his/her beneficiary. The beneficiary may not be
changed after retirement. I hereby apply for regular retirement under the Option 3 Plan.
Signature:
Date:
Option 3a (formerly 4-2) - Pays the retiree a monthly benefit that is reduced from the Maximum. Pays 50% of the monthly benefit for life to the named
retirement beneficiary after the retiree’s death. However, if the named beneficiary predeceases the retiree, the benefit amount will convert
to the Maximum Plan and benefits will cease upon the death of the retiree. The benefit is based on the ages of the retiree and his/her beneficiary.
The retirement beneficiary may not be changed after retirement. I hereby apply for regular retirement under the Option 3a Plan.
Signature:
Date:
RETIREMENT BENEFICIARY INFORMATION
I hereby designate the below named person as my beneficiary to receive benefits as provided under the retirement plan
which I have selected above. I understand that I cannot change the designated beneficiary under any optional retirement
plan or change the retirement plan selected after the effective date of retirement, except in the event of divorce as
provided by R.S. 11:2224C, wherein the spouse, irrevocably, by court order relinquishes survivorship rights under the
option originally selected by the retiree.
Full Name of Beneficiary
Relationship
Social Security No.
Date of Birth
Mailing Address, City, State and Zip Code
**MUST COMPLETE BACK OF FORM**
____Male
____Female
I.
TO BOARD OF TRUSTEES:
I understand that my benefit will be actuarially reduced because I am electing to retire
under the Initial Benefit Option (IBO). I also understand that my original benefit amount
will not be recomputed at anytime and will remain fixed as originally computed.
Signature of Applicant
II.
AGENCY CERTIFICATION – CERTIFIED TRUE AND CORRECT
Municipality:
Date of Last Paycheck:
Authorized Signature:
(To be signed by Appointing Authority)
Phone Number:
Termination Date:
Title:
Email Address:
Date: