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

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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.

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SEAL HERE

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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: