Fillable Form 03-01: Application for Survivor Benefits (La. R.S.

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Form 03-01: Application for Survivor Benefits (La. R.S.

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SECTION 2: APPLICANT'S INFORMATION
PRINT ALL INFORMATION
www.lasersonline.org
Application for Survivor Benefits
(La. R.S. 11:471, 471.1, and LAC 58.I.1901 - 1909)
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
Fax 225.935.2856
Form 03-01
R122018
Date of DeathLast Name
Middle Name
Deceased Member's First Name
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
Zip CodeStateCityApplicant's Mailing Address
Daytime Area Code/Phone Number
Date of Birth
Evening Area Code/Phone Number
Email Address
03-01 R122018 CONTINUE ON NEXT PAGE ERBER5 Page 1 of 3
Social Security Number
Copy of member's Marriage Certificate OR
Copy of death certificate for member Social Security cards for member and all applicants
Single MarriedFemaleMale Divorced Widowed
Active InactiveMember Status:
Last NameMiddle NameApplicant's First Name
Relationship to Member
Female
Male
SECTION 3: REQUIRED DOCUMENTATION (Select any documents which are attached)
Certified copy of Judgement of Divorce OR Copy of spouse's death certificate
Form MSD61, Affidavit of Natural Tutorship of Minor Child, for minor children of deceased member
Form MSD52, Certification for Disabled Survivor, for fully disabled children of deceased member
Birth certificates of all applicants
IMPORTANT: If you are an eligible surviving spouse of a member hired on or after January 1, 2011, survivor benefits are payable to you as long
as you remain unmarried; if you remarry after the member's death, your benefit will be suspended. If you divorce or are widowed from the new
spouse, your benefits will resume. Survivor benefits for surviving spouses of Hazardous Duty Plan members killed in the line of duty will not be
suspended upon remarriage.
For eligible surviving spouses of a Wildlife member hired prior to January 1, 2011, survivor benefits are payable to you as long as you remain
unmarried; if you remarry after the member's death and you are not least age 55 as of the date of remarriage, your benefit will be terminated.
You must notify LASERS immediately in writing if your marital status changes.
Form MSD62, Affidavit of Natural Tutorship of Disabled Child, for fully disabled children of deceased member
Social Security Number
Did the member have a reciprocal agreement with another state retirement system?
Yes NoWas the member in active military duty at the time of death?
Yes No
Social Security Number
NoYes
Disabled?
Female
Male
Zip CodeStateCityMailing Address
Date of BirthLast NameMiddle NameFirst Name
Disabled?
Female
Male
Yes No
Zip CodeStateCityMailing Address
Date of BirthLast NameMiddle NameFirst Name
NoYes
Disabled?
Female
Male
Zip CodeStateCityMailing Address
Date of BirthLast NameMiddle Name
First Name
NoYes
Disabled?
Female
Male
Zip CodeStateCityMailing Address
Date of BirthLast Name
Middle Name
First Name
Full-time unmarried student certification: The high school, vocational/technical school, college, or university must certify that the student
named is a full-time student according to the requirements of that educational institution. The student must remain unmarried and provide
additional certification at the beginning and at mid-term of each semester to continue eligibility for survivor benefits. Any changes in a child or
student's marital status, or any changes in a student's full-time status should be reported to LASERS immediately in writing. All benefits will
cease at age 23, unless the surviving child qualifies as disabled.
Social Security Number
Social Security Number
Social Security Number
Social Security Number
SECTION 4: LIST ALL CHILDREN OF DECEASED MEMBER UNDER AGE 18 OR UNMARRIED FULL-TIME
STUDENTS UNDER AGE 23 (Attach additional sheets if needed)
Last NameMiddle NameFirst Name Date of Birth
Zip CodeStateCityMailing Address
Male
Female
Disabled?
NoYes
Social Security Number
03-01 R122018 CONTINUE ON NEXT PAGE ERBER5 Page 2 of 3
03-01 R102018 RETAIN A COPY FOR YOUR RECORDS ERBER5 Page 3 of 3
Daytime Area Code/Phone Number
Date
Signature of Personnel Officer
Personnel Officer Email Address
Agency 3 digit Number
Name of Agency
TitleName of Personnel Officer
SECTION 7: AGENCY CERTIFICATION
SECTION 6: APPLICANT CERTIFICATION
Date Applicant's Signature
I hereby certify that to the best of my knowledge, I am not aware of any other surviving minor children or qualified surviving spouse of the
above named deceased LASERS member.
SECTION 5: SELECTION OF DISTRIBUTION OPTION - ONLY IF RECEIVING A LUMP SUM PAYMENT
Initials
Initials
I elect to receive a lump sum refund of the contributions made to LASERS by the deceased member named above. I understand
that the refund is taxable in the year that it is received and that 20% federal income taxes will be withheld. The check and 1099
will be sent to the address listed under Section 2 of this form.
I elect to make a qualified direct rollover to the financial institution below. Failure to attach Form 02-01A, Authorization for
Direct Rollover, will delay the rollover.
Name of Financial Institution
Please read the attached multi-page document, "Special Tax Notice Regarding Plan Payments," which explains important tax information,
options, and effects of this transaction. Under provisions of federal law, this distribution is an eligible rollover distribution. It may be rolled
over to a traditional IRA or other qualified plan and remain tax sheltered until disbursed to the payee. If you do not elect the rollover, the
amount you receive will be subject to federal income tax in the year received, and there will be a 20% mandatory tax withholding.
If you are receiving a lump sum payment, please initial ONE of the following two options:
Social Security Number
Was the member killed as a result of an injury or accident on the job in the performance of official duties?
Yes No
If yes, was the member in or eligible to enroll in the Hazardous Duty, Corrections Primary,
Corrections Secondary, Wildlife, or Harbor Police Plan, and was the death due to an intentional
act of violence?
Yes No
If yes, submit Form 3-01A Certification of Death from an Intentional Act of Violence
Reset Form
Special Tax Notice R112011 CONTINUE ON NEXT PAGE Page 1 of 7
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
YOUR ROLLOVER OPTIONS
You are receiving this notice because all or a portion of a payment you are receiving from the Louisiana State
Employees' Retirement System (the “Plan”) is eligible to be rolled over to an IRA or an employer plan. This notice is
intended to help you decide whether to make such a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth
account (a type of account with special tax rules in some employer plans).
Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section.
Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not execute
a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies).
However, if you roll over, you will not have to pay tax until you receive payments later and the 10% additional
income tax will not apply if those payments are made after you are age 59½ (or if an exception applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity)
or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept
the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options,
fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and
IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the
IRA or employer plan.
Special Tax Notice
R112011
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
YOUR ROLLOVER OPTIONS
You are receiving this notice because all or a portion of a payment you are receiving from the Louisiana State
Employees' Retirement System (the “Plan”) is eligible to be rolled over to an IRA or an employer plan. This notice is
intended to help you decide whether to make such a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth
account (a type of account with special tax rules in some employer plans).
Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section.
Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not execute
a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies).
However, if you roll over, you will not have to pay tax until you receive payments later and the 10% additional
income tax will not apply if those payments are made after you are age 59½ (or if an exception applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity)
or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept
the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options,
fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and
IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the
IRA or employer plan.
Special Tax Notice
R112011
Special Tax Notice R112011 CONTINUE ON NEXT PAGE Page 2 of 7
How do I execute a rollover?
There are two ways to execute a rollover: a direct rollover or a 60-day rollover.
If you execute a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You
should contact the IRA sponsor or the administrator of the employer plan for information on how to accomplish
a direct rollover.
If you do not perform a direct rollover, you may still roll over by making a deposit into an IRA or eligible employer
plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not make
a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of
cash and property received other than employer stock). This means that, in order to roll over the entire payment in a
60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount
of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early
distributions if you are under age 59½ (unless an exception applies).
How much may I roll over?
You may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for
rollover, except:
· Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or
joint life expectancy of you and your beneficiary)
· Required minimum distributions after age 70½ (or after death)
· Hardship distributions
· Corrective distributions of contributions that exceed tax law limitations
· Contributions made under special automatic enrollment rules that are withdrawn pursuant to
your request within 90 days of enrollment
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
If I do not execute a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10% additional income tax on early distributions for any payment
from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions
listed below applies. This tax is in addition to the regular income tax on the payment not rolled over.
Special Tax Notice R112011 CONTINUE ON NEXT PAGE Page 3 of 7
The 10% additional income tax does not apply to the following payments from the Plan:
· Payments made after you separate from service if you will be at least age 55 in the year of the separation
· Payments that start after you separate from service if paid at least annually in equal or close to equal amounts
over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)
· Payments from a governmental defined benefit pension plan made after you separate from service if you are a
public safety employee and you are at least age 50 in the year of the separation
· Payments made due to disability
· Payments after your death
· Corrective distributions of contributions that exceed tax law limitations
· Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request
within 90 days of enrollment
· Payments made directly to the government to satisfy a federal tax levy
· Payments made under a qualified domestic relations order (QDRO)
· Payments up to the amount of your deductible medical expenses
· Certain payments made while you are on active duty if you were a member of a reserve component called to
duty after September 11, 2001 for more than 179 days
· Payments of certain automatic enrollment contributions requested to be
withdrawn within 90 days of the first contribution.
If I make a rollover to an IRA, will the 10% additional income tax apply to early distributions from the
IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional income
tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the 10% additional
income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from
a plan. However, there are a few differences for payments from an IRA, including:
· There is no exception for payments after separation from service that are made after age 55.
· The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies
under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA
of a spouse or former spouse).
· The exception for payments made at least annually in equal or close to equal amounts over a specified period
applies without regard to whether you have had a separation from service.
· There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to
$10,000 used in a qualified first-time home purchase, and (3) payments after you have received
unemployment compensation for 12 consecutive weeks (or would have been eligible to receive
unemployment compensation but for self-employed status).
Will I owe State income taxes?
This notice does not describe any State or local income tax rules (including withholding rules).
Special Tax Notice R112011 CONTINUE ON NEXT PAGE Page 4 of 7
SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable
portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax
contributions maintained in a separate account, a special rule may apply to determine whether the after-tax
contributions are included in a payment.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-
day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in
order to determine your taxable income for later payments from the IRAs). If you make a direct rollover of only a
portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable
portion of the after-tax contributions. If you make a 60-day rollover to an IRA of only a portion of the payment
made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a
complete distribution of your benefit which totals $12,000, of which $2,000 is after-tax contributions. In this case, if
you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over
is treated as being after-tax contributions.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a
direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a
governmental section 457(b) plan). You can make a 60-day rollover to an employer plan of part of a payment that
includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the
deadline under certain extraordinary circumstances, such as when external events prevented you from completing
the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a private letter ruling request with
the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS
Publication 590, Individual Retirement Arrangements (IRAs).
If you were born on or before January 1, 1936
If you were born on or before January 1, 1936, and receive a lump sum distribution that you do not roll over, special
rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS
Publication 575, Pension and Annuity Income.
If you are an eligible retired public safety officer and your pension payment is used to pay for health
coverage or qualified long-term care insurance
If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of
disability or was after normal retirement age, you can exclude from your taxable income plan payments paid
directly as premiums to an accident or health plan (or a qualified long-term care insurance contract) that your
employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this
purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or
ambulance crew.
Special Tax Notice R112011 CONTINUE ON NEXT PAGE Page 5 of 7
If you roll over your payment to a Roth IRA
You can roll over a payment from the Plan made before January 1, 2010, to a Roth IRA only if your modified adjusted
gross income is not more than $100,000 for the year the payment is made to you and, if married, you file a joint
return. These limitations do not apply to payments made to you from the Plan after 2009. If you wish to roll over the
payment to a Roth IRA, but you are not eligible to make a rollover to a Roth IRA until after 2009, you can roll over to
a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA.
If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over
(reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on early distributions will
not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the
year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount
can be spread over a 2-year period starting in 2011.
If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not
be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after
you are age 59½ (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000)
and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the
year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified
distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on
early distributions (unless an exception applies). You do not have to take required minimum distributions from a
Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements
(IRAs).
You cannot roll over a payment from the Plan to a designated Roth account in an employer plan.
Special Tax Notice R112011 CONTINUE ON NEXT PAGE Page 6 of 7
If you are not a plan participant
Payments after death of the participant. If you receive a distribution after the participant's death that you do not roll
over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the
10% additional income tax on early distributions and the special rules for public safety officers do not apply, and the
special rule described under the section “If you were born on or before January 1, 1936” applies only if the participant
was born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased
participant, you have the same rollover options that the participant would have had, as described elsewhere
in this notice. In addition, if you choose to make a rollover to an IRA, you may treat the IRA as your own or
as an inherited IRA.
An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before
you are age 59½ will be subject to the 10% additional income tax on early distributions (unless an exception
applies) and required minimum distributions from your IRA do not have to start until after you are age
70½.
If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional
income tax on early distributions. However, if the participant had started taking required minimum
distributions, you will have to receive required minimum distributions from the inherited IRA. If the
participant had not started taking required minimum distributions from the Plan, you will not have to start
receiving required minimum distributions from the inherited IRA until the year the participant would have
been age 70½.
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the
participant's death and you are a designated beneficiary other than a surviving spouse, the only rollover
option you have is to make a direct rollover to an inherited IRA. Payments from the inherited IRA will not be
subject to the 10% additional income tax on early distributions. You will have to receive required minimum
distributions from the inherited IRA.
Payments under a qualified domestic relations order. If you are the spouse or former spouse of the participant who
receives a payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same
options the participant would have (for example, you may roll over the payment to your own IRA or an eligible
employer plan that will accept it). Payments under the QDRO will not be subject to the 10% additional income tax
on early distributions.
If you are a nonresident alien
If you are a nonresident alien and you do not make a direct rollover to a U.S. IRA or U.S. employer plan, instead of
withholding 20%, the Plan is generally required to withhold 30% of the payment for federal income taxes. If the
amount withheld exceeds the amount of tax you owe (as may happen if you make a 60-day rollover), you may
request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for
claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see
also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens
and Foreign Entities.
Special Tax Notice R112011 RETAIN A COPY FOR YOUR RECORDS Page 7 of 7
Other special rules
If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will
apply to all later payments in the series (unless you make a different choice for later payments).
If your payments for the year are less than $200, the Plan is not required to allow you to make a direct rollover and is
not required to withhold for federal income taxes. However, you may execute a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 will be directly rolled over to an IRA chosen
by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before
age 62 (or normal retirement age, if later) and without consent, where the participant's benefit does not exceed
$5,000 (not including any amounts held under the plan as a result of a prior rollover made to the plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see
IRS Publication 3, Armed Forces' Tax Guide.
FOR MORE INFORMATION
You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a
payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments
from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590, Individual
Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These
publications are available from a local IRS office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.
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Form 03-01: Application for Survivor Benefits (La. R.S.

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Completed 6 November 2021

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