LACERS - Forms for Retired Members

Home
Active Members
Retired Members
Board of Administration
Investments
About LACERS

Forms

Forms below are interactive -- you may type information directly onto the form. Once completed, print out the form, sign form (if applicable), and return it to LACERS via mail, fax, or in person:

LACERS

202 W. First Street, Suite 500

Los Angeles, CA 90012-4401

Note: The following forms are in PDF format and are best viewed with Adobe Acrobat® 5.0 or later. Adobe Acrobat Reader can be downloaded for free by clicking on the icon below.

Beneficiary Forms

Affidavit of Retired Domestic Partnership
Designation of Beneficiary for Accrued Allowance of Surviving Spouse or Domestic Partner
Designation of Beneficiary for Community Property
Designation of Beneficiary for Funeral Expense Allowance
Designation of Beneficiary for Unused Contributions and Accrued Payments
Statement of Termination of Retired Domestic Partnership

Health Benefit Forms

Medical Plan Enrollment Form (Kaiser Only)
Medical Plan Enrollment Form (Anthem Blue Cross, SCAN, UnitedHealthcare)
Dental Plan Enrollment Form
Medical and Dental Family Account Change Form
Medical/Dental Cancellation Form
Certification of Dependent or Survivor Status for Health Coverage

Retirement Benefit Forms

Change of Address Request
Direct Deposit Authorization
Direct Deposit Authorization - Larger Annuity
Trustee-to-Trustee Transfer/Direct Rollover Form For Larger Annuity

Tax Forms

Form W-4P Request for Income Tax Withholding
Form W-4P Request for Income Tax Withholding for Larger Annuity
Form W-9 Instructions
Form W-9 Request for Taxpayer Identification Number and Certification

* For dependents between the age of 19 and 25, completing the Student Verification portion of the enrollment form is the first step. Members still must submit additional documents - Proof from school and for Kaiser members the Kaiser Student Certification form.