Certification of Student Status Form MSD14

Form MSD14
R102011
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)
Certification of Student Status
Member's First Name
Middle Name
Last Name
Deceased Member's SSN
SECTION 1: STUDENT'S INFORMATION (TO BE COMPLETED BY APPLICANT)
Middle Name
Student's First Name
Single
Male
Married
Female
Student's Mailing Address
Daytime Area Code/Phone Number
Last Name
Student's Social Security Number
Term: (Ex SPRING 2012)
Birth Date
City
Evening Area Code/Phone Number
State
Zip Code
E-mail Address
SECTION 2: STUDENT'S CERTIFICATION AND AUTHORIZATION
I attest that I am the beneficiary of the above named deceased member of the Louisiana State Employees' Retirement System (LASERS) and
eligible to receive survivor benefits. Based on the definitions I received, I attest that I am a full-time student in full-time attendance at the
school named on this form.
I certify that the foregoing statements are true to the best of my knowledge and belief. I further certify that I will advise LASERS of any
change in my status, including marriage, graduation, suspension, expulsion, or other such cause of voluntary or involuntary non-attendance
at this school or college.
I hereby authorize and consent that the school or college named on this form may release any and all information relative to my enrollment
to LASERS, for the purpose of verifying my eligibility for this benefit which is dependent upon my full-time enrollment. I understand that
an incomplete form will be returned to me to be completed, which may delay my benefits.
Student's Signature
MSD14 R102011
Date
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Student's SSN
SECTION 3: TO BE COMPLETED BY THE SCHOOL OR COLLEGE OFFICIAL
Please type or print all information and complete this form in its entirety. Failure to do so will result in a delay of benefits. Return the
completed form to LASERS at the above mailing address.
High School
Technical, Trade or Vocational School
College or University
Beginning
GED or Adult Education Center
Ending
What are the dates of the current term?
Is the above student enrolled in the current term?
Yes
No
Number of hours enrolled:
Is the above student enrolled full-time?
Yes
No
What is the last date to drop without a grade?
Was the above student full-time in the previous term?
If not full-time, what are the last dates of
enrollment as a full-time student?
Anticipated date of graduation:
Yes
No
Beginning
Number of hours enrolled:
Ending
Credits earned to date:
School Telephone Number
Name of School
Mailing Address
City
State
Printed Name of Authorized Signer
Title
Authorized Signature
Date
University or School Seal
Zip Code
Additional Comments
Reset Form
MSD14 R102011
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SCHCERT Page 2 of 2