RETIREMENT PLAN MEMBERSHIP DISCLOSURE

(Addendum to Delgado Contract for Professional, Personal or Consulting Services)

 

 

The following information is required to ensure compliance with earnable compensation reporting

requirements of the Teachers’ Retirement System of Louisiana (TRSL).

 

Member and employer contributions must be made on 1099 contract earnings that meet specific criteria.

 

 

Please complete, sign, and return this form with your Delgado Contract for Professional, Personal

or Consulting Services.

 

 

Section 1 – Demographic Information

 

Name __________________________________ Social Security #________________

Last, first, MI

 

Address_______________________________________________________________

 

Street/P.O. Box_________________________________________________________

 

City, State, Zip__________________________________________________________

 

 

Section 2 – Retirement Membership Disclosure Information

 

Please indicate whether you are currently a contributing/active member of either of the following

Louisiana public retirement systems through another employer.

 

 

  

  

Yes

No

LASERS [ ] [ ]

TRSL [ ] [ ]

ORP (TRSL) [ ] [ ]

 

Please indicate whether you are a retiree/rehired retiree of either of the following Louisiana public

retirement systems.

 

 

  

  

Yes

No

LASERS [ ] [ ]

TRSL [ ] [ ]

ORP (TRSL) [ ] [ ]

 

 

I certify that the information provided on this form is true and correct.

 

 

 

_______________________________________ ______________________

Signature Date

(3/09)