Fillable Printable Spousal Consent - Louisiana
Fillable Printable Spousal Consent - Louisiana
Spousal Consent - Louisiana
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 ยท Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Spousal Consent
(LAC 58.I.2901)
SECTION 1: SPOUSE'S INFORMATION
Spouse's First Name Middle Name Last Name Spouse's Birth Date
Social Security Number
SECTION 2: INSTRUCTIONS
SECTION 3: SELECTIONS (please select all that apply)
04-04 R122012 RETAIN A COPY FOR YOUR RECORDS SPOUSAL Page 1 of 1
Last Name Today's DateMiddle NameMember's First Name
Form 04-04
R122012
DO NOT FAX FORM
PRINT ALL INFORMATION
www.lasersonline.org
Social Security Number
A married member must choose a retirement option which provides a benefit for their spouse that is at least fifty percent (50%) of the benefit
payable to the retiree. The member may choose a payout with no survivor annuity or name another individual as beneficiary, if the spouse
agrees with the choice and signs the following in the presence of a Notary Public.
Consent to Option Without a Joint and Survivor Annuity for Spouse (to be completed when selecting the Maximum Plan, Option 1, or
a beneficiary who is not the member's spouse)
I understand and acknowledge that my spouse has selected a retirement option or beneficiary on the retirement application that
waives my right to a qualified joint and survivor annuity form of benefit. I hereby consent to such election and permit my spouse
to change his or her beneficiary without my further consent. I understand and acknowledge that by this consent, I give up my
right to a benefit equal to fifty percent (50%) of my spouse's benefit, should I survive my spouse after his or her death.
Spouse's
Initials
Consent to Lump Sum Beneficiary Other than Spouse (to be completed when selecting a Deferred Retirement Option Plan (DROP) or
Initial Benefit Option (IBO) beneficiary who is not the member's spouse)
I understand and acknowledge that, by selecting the retirement option or beneficiary marked on the DROP or IBO retirement
application, my spouse has designated an individual other than myself as his or her DROP or IBO beneficiary. I hereby consent to
such election and permit my spouse to change his or her beneficiary without my further consent. I understand and
acknowledge that by this consent I give up my right to a benefit equal to the balance of my spouse's DROP or IBO account,
should I survive my spouse after his or her death.
SWORN TO AND SUBSCRIBED BEFORE ME, Notary Public, in and for the state of _____________________, parish/county of_______________,
this _______ day of ________, 20____.
____________________________________ _______________________________________
Notary Public (Signature) Notary ID # or Bar Roll #
____________________________________ _______________________________________
Notary Public Name Commission Expires
(affix seal here)
Spouse's Signature Date
Spouse's
Initials
