Forms
All LSERS Portable Document Format (pdf) forms can be downloaded and completed online. You MUST have the Adobe Acrobat Reader (2.1 or higher) installed on your computer to view pdf documents. Please download Adobe Acrobat Reader if needed.
Print the completed form and send it to us by mail or fax. If you are having trouble downloading the form, get help here.
Please be advised that due to a hardware failure, our fax system is temporarily unavailable. Please send all LSERS transmissions to our email address: webmaster@lsers.net.
| All Forms | |
|---|---|
| 1 | Authorized Signatures and Employer Contacts (Online) |
| 2 | Enrollment Application/Employee Notification (Online) |
| 2AC | Change of Address Authorization |
| 2F | Forfeiture of Benefits Attestation |
| 2R | Election to Retain Membership |
| 2SS | Statement Concerning Your Employment in a Job Not Covered by Social Security |
| 3 | Named Beneficiary |
| 4B | Contributions Correction Report (Online) |
| 4C | Contribution Payments Transmittal (Online) |
| 4P | Prior Year Correction of Earnings and Contributions (Online) |
| W4P | Withholding Certificate for Pension or Annuity Payments |
| W4R | Withholding Certificate for Nonperiodic Payments and Eligible Rollover Distributions |
| 4T | Employment Terminations (Online) |
| 5 | Service Credit Verification (Online) |
| 5PT | Report on Part-time Service (Online) |
| 5WC | Report on Workers’ Compensation (Online) |
| 7 | Application for Refund of Member Contributions |
| 7D | Application for Refund of Contributions to Beneficiary |
| 8 | Authorization for Direct Deposit |
| 9 | Application for Transfer or Reciprocal Recognition of Service |
| 9A | Application for Purchase of Service |
| 9RO | Rollover/Trustee-to-Trustee Transfer Acceptance |
| 10 | Application for Service Retirement, IBRP, or DROP |
| 10A | Employer Certification (Online) |
| 10C | Application for Retirement After DROP |
| 11 | Spousal Consent DROP IBRP Account |
| 12 | Application for Disability Retirement |
| 12B | Supervisor Statement of Disability |
| 12C | Physician Report of Disability |
| 13 | Application for Survivor Benefit |
| 13B | Student Certification |
| 13C | Certificate of Heirship |
| 13MC | Natural Tutorship of Minor Child |
| 15 | Re-employment of Retiree – Earnings Report (Online) |
| 15N | Retiree Return-to-Work Notification (Online) |
| 16 | Request for Monthly Benefit Estimate |
| 18 | Member Authorization for Income Verification |
| Members |
|---|
| Update your beneficiary information: 3 |
| Change your address: 2AC |
| Member Authorization for income verification: 18 |
| Request a monthly benefit estimate: 16 |
| Request to purchase service or repay refunded service: 9A |
| Request a transfer of service or reciprocal agreement from a public retirement system: 9 |
| Request a refund of your contributions: 7 |
| Retirees |
|---|
| Change your federal tax withholding: W4P |
| Change your federal tax withholding for nonperiodic payments and eligible rollover distributions: W4R |
| Have your check sent directly to a financial institution: 8 |
| Change your address: 2AC |
| Member authorization for income verification: 18 |
| Update your beneficiary information: 3 |