Designation of Beneficiary Form 01-06

Form 01-06
R062016
PRINT ALL INFORMATION
www.lasersonline.org
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
Fax 225.935.2856
Designation of Beneficiary
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.
SECTION 1: MEMBER'S INFORMATION
Member's Mailing Address
Daytime Area Code/Phone Number
City
State
Evening Area Code/Phone Number
Email Address
Zip Code
Member's Birth Date
SECTION 2: GENERAL INFORMATION
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%
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
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Social Security Number
CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%
Contingent Beneficiary's Name (optional) Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
Contingent Beneficiary's Name (optional) Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
SECTION 4: RETIREMENT BENEFIT BENEFICIARY
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 BENEFICIARIES' PERCENTAGES MUST TOTAL 100%
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%
Contingent Beneficiary's Name (optional) Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
Contingent Beneficiary's Name (optional) Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
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 Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Social Security Number
Male
Female
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Social Security Number
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
Primary Beneficiary's Name
Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
CONTINGENT BENEFICIARIES' PERCENTAGES MUST TOTAL 100%
Contingent Beneficiary's Name (optional) Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
Contingent Beneficiary's Name (optional) Relation, Trust, Estate
Birth Date
Percentage
Male
Social Security Number
Female
SECTION 6: MEMBER SIGNATURE
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.
Member's Signature
Date
Reset Form
01-06 R062016
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