Form 5-01 - Request For Retirement Benefits Estimate

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Form 5-01
R012017
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
Request for Retirement Benefits Estimate
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
Check one:
Female
Male
SECTION 2: GENERAL INSTRUCTIONS
You must be within 18 months of retirement or DROP eligibility to request an estimate. Estimates are limited to one request per year from the
date of your current request. (Example: If you request an estimate on 05/01/15, your next estimate request must be after 05/01/16.)
SECTION 3: REQUIRED INFORMATION FOR ESTIMATE
Estimated Retirement Date
Unused Annual Leave - in Hours (less 300 hours)
Unused Sick Leave - in Hours
Relationship to Member
Beneficiary's First Name
Middle Name
Last Name
Beneficiary's Birth Date
Beneficiary Gender:
Female
Male
Check one:
I am currently working for a LASERS agency. Agency name:
I am no longer working in state service.
Employment Type (Check one):
Regular
Judicial
Wildlife
Peace Officer
Revenue (ATC)
Correctional
Legislative
Bridge Police
Law Clerk
HAZ Plan
Other ________________
5-01 R012017
CONTINUE ON NEXT PAGE
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