Designation of Beneficiary Form 01-06

Form 01-06
R122012
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
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
Check at least one:
City
State
Email Address
Evening Area Code/Phone Number
Active Member (Do not check this box if you
are retired or have entered DROP)
Single
Married
Zip Code
Member's Birth Date
Divorced
Widowed
Retired Member - Retirement Benefit
Retired Member - DROP/IBO Account
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: DESIGNATION OF BENEFICIARY
PRIMARY BENEFICIARIES' PERCENTAGES MUST TOTAL 100%
Primary Beneficiary's Name (required)
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
Male
Social Security Number
Female
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 4: 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
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01-06 R122012
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