Would you like your address changed to the one listed above if it does not agree with the address on our records?
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.
Full Refund Amount
Number of full years
RETAIN COPY FOR YOUR RECORDS
PRINT OR TYPE ALL INFORMATION
Member's First Name Middle Last
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)
Daytime Area Code and Telephone Number
Evening Area Code and Telephone Number
Member's Mailing Address
City State ZIP
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