Forms

Overview November 26, 2019

The Forms Library will serve as the central hosting and retrieval application for all LACERS forms and documentations. The Forms Library will allow external users to search and filter across a variety of categories with all forms/documentation available for download.

Post January 23, 2020

Beneficiary Forms

Current Employees

Designation of Beneficiary for Active Members - Tier 1

Retirees

Designation of Beneficiary for Accrued Allowance of Surviving Spouse or Domestic Partner
Designation of Beneficiary for Unused Contributions and Accrued Payments
Designation of Beneficiary for Community Property
Designation of Beneficiary for Funeral Expense Allowance

Post January 30, 2020

Change of Address

Change of Address Request Form

Change of Email Address Request Form

Post January 30, 2020

Direct Deposit Authorization

Direct Deposit Authorization Form

Post December 10, 2019

Distribution Election Form

Distribution of Election Form

Post February 12, 2020

Domestic Partnership

Members
Declaration of Domestic Partnership
Termination of Domestic Partnership

Retirees
Affidavit of Retired Domestic Partnership
Statement of Termination of Retired Domestic Partnership

Post March 17, 2020

FDBP

Cancellation of Election to Participate in Family Death Benefit Plan
Election to Participate in Family Death Benefit Plan

Post January 30, 2020

Health Benefit Forms*

2021 Open Enrollment Overview
2021 Medical/Dental Family Account Change Form
2021 Medical Plan Enrollment Form (Non-Kaiser)
2021 Medical Plan Enrollment Form (Kaiser)
2021 Dental Plan Enrollment Form
Certification of Dependent or Survivor Status for Health Coverage
Medicare Information Acknowledgement Form

*Contact LACERS if you need enrollment forms for the following plans:

Anthem Blue Cross Life and Health
Kaiser Permanente Senior Advantage
UnitedHealthCare Medicare Advantage
SCAN Medicare Advantage

Post December 10, 2019

Information Sheets

Back Contribution Information Sheet
Back Contribution Information Sheet for Participants of the Pension Savings Plan
Excess Benefit Program Fact Sheet
FDBP Information Sheet
Tier 1 - Government Service Buyback Information Sheet
Tier 3 - Government Service Buyback Information Sheet
Hiring Hall Service Credit Purchase Information Sheet
Public Service Buyback Information Sheet
Reciprocity Information Sheet
Re-deposit Information Sheet
Your LACERS Health Plan Subsidy

Post January 24, 2020

Larger Annuity Program

Larger Annuity - Initiation or Change of Contribution Amount
Larger Annuity - Distribution Election Form
Larger Annuity - Direct Deposit Authorization
Larger Annuity - Election to Change Investment Option or Terminate Bi-Weekly Contributions
Tax Notification
Trustee-to-Trustee Transfer/Direct Rollover Form For Larger Annuity
Larger Annuity Fact Sheet

Post January 30, 2020

Power of Attorney

LACERS Special Durable Power of Attorney Form (For LACERS Use Only)
LACERS Special Durable Power of Attorney Fact Sheet

Post January 29, 2020

Retirement Application Forms

Before accessing the Managed Service Retirement Application or the Vested Service Retirement Application, please refer to the following retirement application Do’s and Don’ts during the retirement process:

Retirement Application Do’s and Don’ts
Do’s	Don’ts
DO sign and date your application	DO NOT sign your application electronically
DO submit ALL three (3) pages of your Managed Retirement Application	DO NOT use any white-out on your application
DO initial any cross-outs	DO NOT put a past date as your Retirement Effective Date
DO make sure your application is submitted within the filing period	DO NOT submit your application in a format where it is not legible

Managed Service Retirement Application
APO Managed Service Retirement Application
Vested Service Retirement Application
Questionnaire for New Retirees - All Members
Questionnaire for Vested Retirees - All Members
Member Information Sheet

Post May 12, 2021

Retirement Decision Sheet

Post December 10, 2019

Service Credit Purchase & Reciprocity

Application to Purchase Public Service Form
Application to Purchase Previous City Service
Certification of Service - All Members
Certification for Hiring Hall Service Purchase
Certification of Uncompensated Maternity Leave
Election Not to Participate in DWP Reciprocity

Post January 30, 2020

Tax Forms

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

Post September 3, 2020

Verification of Pension Request

Verification of Pension Request Form

Current Employees

Retirees

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