Application for Retired Membership

Name*
First Middle Last
Gender
- Male
- Female
Former Department*
Last Held Rank/Title*
Date Entered County Service*
Date Format: MM slash DD slash YYYY
Date Retired County Service*
Date Format: MM slash DD slash YYYY
Last 4 digits of SSN*
Home Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
Personal Email*
Deduction Agency*
Deduction Code*
Monthly Membership Dues Deduction*
- Retired prior to 1980
- Retired 1980 or later
Star & Shield Charitable Foundation*
Voluntary charitable monthly deduction
- $2
- $5
- $10
- $20
- Other
- Decline
Other Amount*
Total
$0.00
I hereby authorize the Board of Retirement to cancel the deduction, or to deduct monthly from my retirement warrants issued by Los Angeles County Employees Retirement Association (LACERA), the amount shown hereon and to pay the same to the proper agent. This authorization cancels and replaces any previously signed by me for this purpose and shall remain in effect until cancelled by me, by written notice. It is expressly understood and agreed that the Board of Retirement or other disbursing officer acting under this authorization shall not be liable in any manner for failure or delay on his part in making the deductions or payments here authorized and I agree to save the Board of Retirement or other disbursing officer harmless from any loss sustained by me for his failure or delay in making any such deductions or payments.
Signature*
Signature Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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