Would you like your address changed to the one listed above if it does not agree with the address on our records?
Yes
No
SECTION 2: DATES OF REFUNDED SERVICE AND AGENCY NAME
From (MM/DD/YYYY) To (MM/DD/YYYY) Agency Name
If you would like the cost to repay part of a refund, please indicate the approximate number of years and indicate if you also want the cost for the full refunded amount.
Number of partial years
Check one or both:
Partial Refund Amount
SECTION 3: OTHER INFORMATION
Please list other names service might be under.
SECTION 4: AUTHORIZATION
I have read and understand this application to purchase refunded service credit and certify, to the best of my knowledge, all information provided is true and correct. I
understand that an incomplete application will be returned and that it will delay the process to purchase this service credit.
Member's Signature
Date (MM/DD/YYYY)
Full Refund Amount
Number of full years
RETAIN COPY FOR YOUR RECORDS
PRINT OR TYPE ALL INFORMATION
Today's Date
Member's First Name Middle Last
(MM/DD/YYYY)
Social Security Number
IMPORTANT: Complete the entire form. Follow the specific instructions for each section.
SECTION 1: MEMBER'S STATEMENT (To be completed by applicant)
Member's Birthdate
(MM/DD/YYYY)
Daytime Area Code and Telephone Number
Evening Area Code and Telephone Number
2-11
R0507
E-mail Address
Member's Mailing Address
City State ZIP
*REPYREQ*
Louisiana State Employees' Retirement System
P.0. Box 44213, Baton Rouge, LA 70804-4213 • 225-922-0600 • Toll-Free 1-800-256-3000
DO NOT FAX FORM
Application for Repayment of Refunded Service
www.lasersonline.org
