Forms For Retired City Employees

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.

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.

• Affidavit of Retired Domestic Partnership
• Change of Address Request
• Designation of Beneficiary for Community Property
• Designation of Beneficiary for Funeral Expense Allowance
• Designation of Beneficiary for Unused Contributions and Accrued Payments
• Direct Deposit Authorization
• Direct Deposit Authorization - Larger Annuity
• Form W-4P Request for Income Tax Withholding
• Form W-4P Request for Income Tax Withholding for Larger Annuity
• Form W-9 Instructions (Rev. October 2004)
• Form W-9 Request for Taxpayer Identification Number and Certification (Rev. January 2003)
• Medical and Dental Plan Cancellation Form
• Medical and Dental Plan Enrollment Form * and Information Sheet
• Medical and Dental Plan Family Account Change Form * and Information Sheet
• Statement of Termination of Retired Domestic Partnership
• Trustee-to-Trustee Transfer/Direct Rollover Form For Larger Annuity

* 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.