Form 02-05 Lasers Louisiana State Employees' Retirement System - Certification For Purchase Of In-State Service
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1
2Form 02-05
R022013
DO NOT FAX FORM
PRINT ALL INFORMATION
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Certification for Purchase of In-State Service
(La. R.S. 11:422)
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
You may be entitled to receive credit for any full-time Louisiana state service for which you have not received credit, except for service
specifically excluded by law. Credit shall not be allowed for employment when per diem allowances were paid in lieu of earned compensation,
except for legislative service; for part-time service not authorized under La. R.S. 11:162(C) or contractual employment; employment as a patient
or inmate help in a state charitable, penal, or correctional institution; employment as a student, medical intern, or resident physician;
employment as a teacher in an educational institution of this state; employment while a member of any other retirement system established by
law; and employment with any state agency or governing body whose employees are not contributing members of the Louisiana State
Employees' Retirement System (LASERS).
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 on or after January 1, 2011
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
Peace Officer, hired prior to January 1, 2011
Alcohol & Tobacco Control Agent employed by the Louisiana Department of Revenue, hired prior to January 1, 2011
Wildlife Agent employed by the Enforcement Division of the LA Wildlife & Fisheries Commission, hired prior to January 1, 2011
02-05 R022013
CONTINUE ON NEXT PAGE
CERTIFIC Page 1 of 2
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