Special Power Of Attorney
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5Special Power of Attorney
888 CalPERS (or 888-225-7377)
TTY for Speech and Hearing Impaired: (916) 795-3240
Fax (916) 795-3934
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Creation of Durable Power of Attorney for Retirement-Related Business
Section 1
–
–
When completing this form,
Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number
please be sure to print the
requested information.
Address
County
For the purpose of this
(
)
form, a principal is
City
State
ZIP
Daytime Phone
defi ned as a person who
By this document I intend to create a durable power of attorney by appointing the person(s) named
empowers another to act
below to make retirement-related decisions for me as allowed by the California Probate Code. This
as a representative on
power is expressly limited to decisions relating to my fi nancial and health benefi ts under the California
their behalf.
Public Employees’ Retirement System, the Legislators’ Retirement System, or the Judges’ Retirement
System I or II — hereinafter CalPERS, LRS, JRS I and JRS II, respectively.
Designation of Attorney-In-Fact
Section 2
If you appointed more than one attorney-in-fact, and you want each attorney-in-fact to be able to act
You have the option of
designating more than one
alone, check the appropriate box. If you do not check a box, or if you check “jointly,” then all of your
attorney-in-fact.
attorneys-in-fact must act or sign together. Granting joint authority to two or more attorneys-in-fact is
exercisable only by their unanimous action. If you choose to have your attorneys-in-fact act jointly, and one
is unavailable because of absence, illness, or other temporary incapacity, the other attorney(s)-in-fact may
exercise their authority under the power of attorney.
Name of attorney-in-fact
Address
County
(
)
City
State
ZIP
Daytime Phone
Name of attorney-in-fact
Address
County
(
)
City
State
ZIP
Daytime Phone
Name of attorney-in-fact
Address
County
(
)
City
State
ZIP
Daytime Phone
I have designated more than one attorney-in-fact. They are to act (mark one box only):
F
F
F
Jointly
Separately
Alternately, in the numerical order specifi ed above. If you mark “Alternately,”
you must number the attorneys-in-fact in the order in which they are to act.
PERS-OSS-138 (8/09)
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