LOS ANGELES COUNTY FIREMEN’S RELIEF ASSOCIATION
P.O. BOX 91-1113
COMMERCE, CA. 90091
APPLICATION
FOR
RETIREMENT BENEFITS
Date: _______________
Board of Directors
Los Angeles County Firemen’s Relief Association
P.O. Box 91-1113
Commerce, CA. 90091
Gentlemen:
Being a member in good standing of the Los Angeles County Firemen’s Relief Association
and having been placed on ______________________________________ Retirement by the
(Service / Disability)
Los Angeles County Board of Retirement, effective as of ______________________, I hereby
(Date of Retirement)
make an application for whatever benefits I may be entitled to in connection with such retirement
from active service.
4112. Time limit to file claims: Claims for benefits must be on file with the Association not later than three months from
(a) conclusion of temporary disability, (b) retirement, (c) classification by Board of Retirement as permanent disability,
(d) death, or (e) termination, as the case may be.
______________________________________________ ___________________
(
Print Name) (Employee Number)
_____________________________________________________________ __________________________
(Street Address) (Phone Number)
_____________________________________________________________ __________________________
(City) (Zip Code)
_______________________________________________
(Signature)
DO NOT WRITE IN THIS SPACE
APPROVED: _____________________ RETIREMENT ACCOUNT NO: _______________________
CHECK NO: ______________ AMOUNT: $_____________________ DATE PAID: _____________________
Rcvd______ LACERA______ Min.______
Revised 01/08
