Change of Address Form 1-02

Form 1-02
R082010
ERBER16
DO NOT FAX FORM
PRINT ALL INFORMATION
www.lasersonline.org
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Change of Address
Member's First Name
Middle Name
Last Name
Today's Date
Social Security Number
IMPORTANT: Complete the entire form. Follow the specific instructions for each section. All dates should be in MM/DD/YYYY format.
This form cannot be used for active members or inactive members who have been out of state service for less than six months. These
members must change their address through their employing agency. This form should be used for inactive members who have been out of
state service for more than six months, DROP participants, and retired members.
SECTION 1: MEMBER'S INFORMATION
Daytime Area Code/Phone Number
Evening Area Code/Phone Number
E-mail Address
Member's Birth Date
SECTION 2: PAYEE INFORMATION
Payee's First Name
Daytime Area Code/Phone Number
Middle Name
Last Name
Social Security Number
Evening Area Code/Phone Number
E-mail Address
Payee's Birth Date
SECTION 3: ADDRESS CHANGE
I request that my address be changed as follows (Check ALL that apply):
Inactive member (out of state service for at least six months)
Retired Member or Payee - All Accounts: this will change your address for all retirement correspondence, monthly benefit checks and
DROP/IBO Account checks.
Retired Member or Payee - Only LASERS DROP/IBO Account: this will change your address for your DROP/IBO Account checks only.
The address for your monthly benefit check will not be changed.
FORMER Home Mailing Address
City
NEW Home Mailing Address
State
Zip Code
City
State
Zip Code
SECTION 4: MEMBER/PAYEE SIGNATURE
I hereby request that my address be changed as designated above.
Member/Payee's Signature
Date
Reset Form
1-02 R082010
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