Louisiana State Employees' Retirement System - Application For Purchase Of Leave
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1
2Form 02-10
R062016
PRINT ALL INFORMATION
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
Fax 225.935.2856
Application for Purchase of Leave
(La. R.S. 11:163)
Member's First Name
Middle Name
Last Name
Today's Date
Social Security Number
IMPORTANT: Complete the entire form. Follow the specific instructions for each section. All dates should be in MM/DD/YYYY format.
SECTION 1: MEMBER'S INFORMATION
Member's Mailing Address
City
State
Zip Code
Daytime Area Code/Phone Number
Evening Area Code/Phone Number
Email Address
Member's Birth Date
SECTION 2: INSTRUCTIONS
Check one of the following options:
I wish to purchase service and salary credit for each day that I was involuntarily furloughed due to the temporary closure of my employer
or a gubernatorially declared disaster or emergency.
I wish to purchase service credit for each day that I was placed on or voluntarily took leave without pay.
You must pay a nonrefundable fee of $150.00 to LASERS for the actuarial calculation. This fee may be paid by personal check, cashier's
check, certified check, or money order made payable to LASERS and should accompany this application. There will be a $15.00 charge for
all checks returned due to insufficient funds.
Indicate which LASERS plan applies to you by checking the appropriate box below:
Regular Member, hired prior to July 1, 2006
Regular Member, hired between July 1, 2006 and December 31, 2010
Regular Member, hired between January 1, 2011, and June 30, 2015
Regular Member, hired on or after July 1, 2015
Bridge Police Employee for the Crescent City Connection (DOTD), hired prior to January 1, 2011
Correctional Officer, Security Personnel, or Probation & Parole Officer employed by the LA Department of Public Safety & Corrections,
hired prior to January 1, 2011
02-10 R062016
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