LOS ANGELES COUNTY
RELAC MEMBERSHIP APPLICATION
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SS #
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NAME OF RETIREE
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ADDRESS (Apt.,Unit,Sp.,etc.)
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CITY, STATE, ZIP
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TELEPHONE
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DATE RETIRED (Month, Year)
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DEPARTMENT
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BIRTH DATE
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MONTHLY DUES $2.00
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NAME OF SPOUSE
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MONTHLY DUES $ .50
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TOTAL MONTHLY DEDUCTION
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SPOUSE SS #
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SPOUSE BIRTH DATE:
| I hereby authorize the Board of Retirement to deduct monthly from my
retirement warrant the amount shown hereon and to pay the same to RELAC. If survived by spouse, he/she shall continue as a member at .50 a month, unless cancelled by written notice. |
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SIGNATURE OF RETIREE
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DATE
| [ ] I am not yet retired. My RELAC membership and the payments
authorized above should begin when my retirement becomes effective. My expected retirement date is: Month _______Year____________ |