Disability Retiree Earned Income Statement

4-3
R0411
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www.lasersonline.org
IMPORTANT: Complete the entire form.
Follow the specific instructions for each section.
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Disability Retiree Earned Income Statement
SECTION 1: INSTRUCTIONS
You must complete this form detailing your earned income in the previous tax year (even if you had no
earned income). Your signature must be witnessed by a Notary Public. Only income earned from a nonstate (private) employer should be submitted. Do not include any income earned from your previous state
agency, if you took a disability retirement during the previous calendar year. LASERS must receive this
form, copies of your previous year's W-2(s), 1099(s) and tax return no later than May 1. If you are not
required to file a tax return for the previous tax year, please indicate this in Section 3. Failure to submit this
form to LASERS at the address above by May 1 will result in the discontinuance or revocation of your
benefits beginning June 1.
SECTION 2: MEMBER'S STATEMENT (To be completed by applicant)
Member's First Name
Middle
Member's Birth Date
Last Name
Today's Date
Daytime Area Code/Phone Number
Evening Area Code/Phone Number
Social Security Number
E-mail Address
SECTION 3: TOTAL GROSS EARNINGS (Do not include disability retirement benefits or earnings from your former state agency.)
$
earned in
year
. If you had no earnings, enter "0" (zero).
Check here if you were not required by the Internal Revenue Service to file a __________ tax year return.
SECTION 4: RETIREE'S SIGNATURE
City
Retiree's Signature
State
Zip Code
Street Address
Would you like your address changed to the one listed above if it does not agree with the address on our records?
Yes
No
SECTION 5: NOTARIZED SIGNATURE
The retiree's signature must be signed in the presence of a Notary Public (signature required to be valid).
SWORN TO AND SUBSCRIBED BEFORE ME, Notary Public, in and for the state of _________________,
parish/county of ____________, this ________________________ day of _____________ , 20 ______________.
NOTARY PUBLIC (Signature)
(affix seal here)
NOTARY PUBLIC (type, print or stamp name)
Notary ID # or Bar Roll #
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