Fillable Printable Limited Durable Power of Attorney Form - Connecticut
Fillable Printable Limited Durable Power of Attorney Form - Connecticut
Limited Durable Power of Attorney Form - Connecticut
Power of Attorney - Pre Retirement
State Employees Retirement System
NEW CO-1049 Page 1 of 2
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
PART I - GENERAL INFORMATION AND INSTRUCTIONS - PLEASE READ CAREFULLY
Connecticut statutes allow an entity to establish its own criteria as to what it will accept with regard to a LDPOA. In order to
safeguard the interests of members of the State Employees' Retirement System ("SERS") a member wishing to designate
someone as his or her Attorney-In-Fact must use this form to do so. This LDPOA authorizes your Attorney-In-Fact to perform on
your behalf any transactions with SERS that you could request yourself. This form is intended for use with SERS only. Every
LDPOA is subject to review and approval by SERS. This two page document must be signed, dated, witnessed and
notarized where indicated.
LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - PRE RETIREMENT
PART II - MEMBERS (PRINCIPAL) INFORMATION (Type or Clearly Print This Information)
The individual you wish to designate as your Attorney-In-Fact (Agent)
Directions: If you have not yet retired: Fill in and otherwise execute both pages of this LDPOA form and send or give to your
employing agency. Your agency will forward the original LDPOA (both pages) with any relevant or necessary documentation to
the Retirement Services Division, 55 Elm Street, Hartford, CT., 06106.
Date
1. This document gives the person you designate the power to make any and all decisions for your SERS related matters on
your behalf. SERS is providing this instrument to its members as a matter of courtesy: due to the significance of this
document SERS strongly recommends that you seek legal advice before signing this document.
2. This document remains in effect until the earliest of the following occurs: (a) a period of five years from the date it is
signed; (b) SERS has knowledge of your death; (c) your Attorney-In-Fact relinquishes his/her duties or a court acting on
your behalf terminates such authority; (d) you revoke this LDPOA by written notification to SERS. This LDPOA may not
be amended.
3. If your Attorney-In-Fact is your spouse, SERS shall presume and deem this LDPOA revoked if either you or your spouse
files for divorce unless you specifically write and notify us otherwise.
4. This LDPOA presumes you are of sound mind when you execute it. It will continue despite any incapacity or disability you
may suffer after execution. However, it is limited to a period of five years from the date of your signature. If you wish it to
continue after five years, you must execute another LDPOA.
5. With the exception of a spouse, the "Attorney-In-Fact" listed on the POA cannot also be your contingent annuitant or
beneficiary unless you have specifically noted this on the form provided.
MEMBER'S NAME (Last, First, M.I.)
EMPLOYEE NO.
SOC SEC NO.
MEMBER'S ADDRESS (Street, No., Name)
(City, State, Zip Code)
PART III - DESIGNATION OF ATTORNEY- IN-FACT (AGENT) (Type or Clearly Print This Information)
PART IV - AGREEMENT AND ACKNOWLEDGEMENT
I have read or have had explained to me the information contained on this page, page one of this two page LDPOA form, and I
understand its contents. I understand that I am also referred to as the Principal in and throughout this document.
NAME (Last, First, M.I.)
ADDRESS (Street, No., Name)
(City, State, Zip Code)
SOC SEC NO.
(Print Clearly or Type)
RELATIONSHIP
Name of Member (Principal)
Power of Attorney Pre Retirement
State Employees Retirement System
NEW CO-1049 Page 2 of 2
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - PRE RETIREMENT
I hereby give (name) my Attorney-In-Fact who was designated as my Attorney-In-Fact
on the first page of this two page form, the full power and authority to engage in retirement plan transactions on my behalf with
SERS to the extent that I could do myself as a member of SERS in accordance with the SERS statutes. My Attorney-In-Fact
shall be authorized to do the following with regard to my SERS' pension benefits ( note: check all that you DO authorize):
Talk to my employing Agency and Retirement Services Division staff about my benefit to learn and/or
receive the information necessary for retirement.
To make any and all designations concerning the method of payment of these sums, including the
designation of the address or bank account to which the benefits are sent or deposited.
I understand that SERS does not permit a non-spouse Attorney-In-Fact acting on behalf of a member to name themselves as a
beneficiary or contingent annuitant unless I specifically allow my Attorney-In-Fact to do so. By placing my initials (not just a
check mark) on the line next to the following statement, I agree and hold that:
To the extent that I could do so myself under SERS, and while it may be construed as self-dealing, my
non-spouse Attorney-In-Fact (name) may name himself or herself
as beneficiary or as a contingent annuitant with regard to any SERS related retirement benefit.
By signing this form. I am granting (name of agent) the full power and authority to
act on my behalf with regard to the SERS transactions I have marked above. I understand the legal impact in executing this
LDPOA and hereby agree to hold SERS, the State of CT and its employees harmless for any alleged misuse, mismanagement or
malfeasance by the Attorney-In-Fact exercising any and/or all powers granted under this LDPOA. Furthermore, no State
employee who relies in good faith upon the authority granted hereunder shall incur any liability to me, my estate, my heirs
successors or assigns.
IN WITNESS WHEREOF, I have signed this Power of Attorney on
Statement of Witness: I declare that the principal has identified himself or herself to me, that the principal signed or
acknowledged this limited durable power of attorney in my presence, that I believe the principal to be of sound mind, that the
principal has affirmed that the principal is aware of the nature of the document and is signing it voluntarily and free from duress.
Notary certification: On this day before me, a Notary Public or Commissioner of the Superior Court, authorized to administer
oaths in the State that the Member resides, personally appeared (member/Principal) who is personally
known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed as the Principal
within this instrument, executed this document in my presence, and personally acknowledged to me that he/she executed this
Power of Attorney for the purposes herein stated.
Select payment election options in accordance with the SERS statutes.
Execute SERS retirement related forms, instruments and applications as appropriate.
Designate beneficiaries and survivor annuitants in accordance with SERS statutes and procedures.
Receive pre-retirement counseling on my behalf.
, 20
SEAL HERE
, 20
Signature of Member (Principal)
Address (Street/Town/State) Where Signed
Signed and sworn before me this
day of
Signature of Notary Public:
State:
Town:
My commission expires
Witness Signature:
Date signed:
Address:
Witness Signature:
Date signed:
Address:
