Fillable Form 13-R - Renunciation Of Beneficiary printable pdf download

Form 13R (02/04)

Teachers’ Retirement System of Louisiana

8401 United Plaza Boulevard

02-13R

Baton Rouge, LA 70809-7017

Telephone: (225) 925-6446

Submit original form

no fax copies accepted

Renunciation of Beneficiary

STATE OF

____________________________________________

PARISH/COUNTY OF ____________________________________________

BE IT KNOWN, That on this ______________ day of _________________________________, 20_______, before me,

________________________________________, Notary Public duly commissioned and qualified in and for the Parish/County

of ________________________________, State of _______________________________________, therein residing, and in the

presence of the witnesses hereinafter named and undersigned:

PERSONALLY CAME AND APPEARED, ____________________________________, who declares as follows, to wit:

That _______________________________________ is the surviving spouse/child of the deceased, who was an active

contributing member of the Retirement Fund Account in the name of said _________________________________, with the

Teachers’ Retirement System of Louisiana, Social Security No. ___________________________________; that as the surviving

spouse/child is entitled to a monthly payment of approximately $______________________________, that appearer does, by

these present, hereby fully, finally and forever renounce and abrogate, jointly and severally,

____________________________________ rights to surviving spouse/child monthly payments; appearer further stated that

____________________________________ intent in making such renunciation is such that the designated beneficiary of said

deceased member, namely ____________________________________, may receive a lump sum payment of the accumulated

contributions under the provisions of the Retirement System.

THUS DONE AND PASSED IN MY OFFICE IN __________________________________________, in the presence of

_____________________________________________ and _____________________________________________, competent

witnesses, and me, Notary, on the date first written hereinabove.

_________________________________

Beneficiary Social Security Number

Beneficiary name, printed

Beneficiary signature

_________________________________

Witness name, printed

Witness signature

_________________________________

Witness name, printed

Witness signature

_________________________________

Notary Public Identification/Bar Roll Number

Notary Public name, printed

Notary Public signature

Form 13-R - Renunciation Of Beneficiary