Change of Address

*ERBER16*

Louisiana State Employees' Retirement System

1­2

R0906

P.0. Box 44213, Baton Rouge, LA 70804­4213 • 225­922­0600 • Toll­Free 1­800­256­3000

PRINT OR TYPE ALL INFORMATION

Member's First Name Middle Last

Today's Date

(MM/DD/YYYY)

Social Security Number

SECTION 2: RECIPIENT INFORMATION

IMPORTANT:

Complete the entire form. Follow the specific instructions for each section.

Check One:

Daytime Area Code and Telephone Number

Member's Birthdate

(MM/DD/YYYY)

Evening Area Code and Telephone Number

SECTION 3: ADDRESS CHANGE

Former Home Mailing Address

New Home Mailing Address

City State ZIP

City State ZIP

Agency Name

Please print and sign this form. Mail the form to LASERS at the above address.

I hereby request that my address be changed as designated above.

SECTION 4: MEMBER CERTIFICATION

Member/Recipient's Signature

Date (MM/DD/YYYY)

WITNESSED BY:

LOUISIANA STATE EMPLOYEES' RETIREMENT SYSTEM Employee

(

Signature)

SWORN TO AND SUBSCRIBED BEFORE ME, Notary Public, in and for the state of ________________________________, parish/county of _________________________, this

________________________ day of ________________ , 20 ___________ .

Commission Expires:

(affix seal here)

SECTION 5: AUTHORIZATION, IF NECESSARY

Only complete this section if signing with an "X" or your signature has changed due to health reasons. You must

sign in the presence of either a LASERS representative or a Notary Public in one of the areas below.

RETAIN COPY FOR YOUR RECORDS

DROP Participant: Member has selected DROP and has not yet terminated employment.

I request that my address be changed as follows;

Check

all

that apply:

Recipient's Birthdate

(MM/DD/YYYY)

Recipient's Social Security Number

Recipient's First Name Middle Last

OR

NOTARY PUBLIC (Signature)

Notary ID # or Bar Roll #

www.lasersonline.org

DO NOT FAX FORM

NOTARY PUBLIC (Type, print or stamp name)

LASERS Employee Name

(Type or print)

Member Email Address

Agency Number (3­digits)

E­mail Address Change, if applicable

Recipient's E­mail Address

SECTION 1: MEMBER INFORMATION

Active: Member has not yet retired.

Retired: Member is receiving a monthly retirement benefit.

Daytime Area Code and Telephone Number

Evening Area Code and Telephone Number

 

Active: This selection will change your address if you are an active member of LASERS.

 

Retired: This selection will change your address for all: retirement correspondence, monthly retirement benefits checks and monthly LASERS

DROP/IBO account checks.

 

LASERS DROP/IBO Account: This selection will change your address for the monthly LASERS DROP/IBO account checks and LASERS DROP/IBO

account information ONLY. The address on your monthly retirement benefit check will not be changed.

 

Recipient: This selection will change your address for all correspondence, all monthly benefit checks and all monthly LASERS DROP/IBO account

checks.