%PDF-1.3 %âãÏÓ 1 0 obj << /Producer (OmniForm Converter for PDF) /Creator (OmniForm Premium) >> endobj 4 0 obj [ /PDF /Text ] endobj 6 0 obj << /Length 7 0 R >> stream BT /F0 10 Tf 0 g 19.089 754.183 Td (Power of Attorney - Pre Retirement) Tj 0 -11.469 Td (State Employees Retirement System) Tj 0 -11.469 Td (CO-1049 Rev. 8/2015) Tj 0 -11.469 Td (Page 1 of 2) Tj /F1 10 Tf 399.773 32.607 Td (STATE OF CONNECTICUT) Tj -32.797 -11.469 Td (OFFICE OF THE STATE COMPTROLLER) Tj 12.5 -11.469 Td (RETIREMENT SERVICES DIVISION) Tj ET 1 w 0 G 0 J 17.997 695.891 m 594.323 696.552 l S 0 J 17.906 676.012 m 592.912 676.012 l S 0 J 18.238 694.312 m 593.992 694.312 l S 0 J 18.238 696.878 m 593.992 696.878 l S BT /F0 10 Tf 19.647 682.002 Td (PART I - GENERAL INFORMATION AND INSTRUCTIONS - PLEASE READ CAREFULLY) Tj ET .75 w 0 J 328.958 633.702 m 350.614 633.702 l S 0 J 265.603 610.764 m 282.271 610.764 l S BT /F1 10 Tf 19.953 657.887 Td (Connecticut statutes allow an entity to establish its own criteria as to what it will accept with regard to a Limited Durable Power of) Tj 0 -11.469 Td (Attorney \(LDPOA\). In order to safeguard the interests of members of the State Employees' Retirement System \(SERS\) a) Tj 0 -11.469 Td (member wishing to designate someone as his or her Attorney-In-Fact ) Tj (must) Tj ( use this form to do so. This LDPOA authorizes your) Tj 0 -11.469 Td (Attorney-In-Fact to perform on your behalf any transactions with SERS that you could request yourself. This form is intended for) Tj 0 -11.469 Td (use with SERS only. Every LDPOA is subject to review ) Tj (and) Tj ( approval by the Retirement Services Division \(RSD\). ) Tj /F0 10 Tf (This two page) Tj 0 -11.469 Td (document must be signed, dated, witnessed and notarized where indicated.) Tj ET 1 w 0 J 19.378 355.3 m 594.383 355.3 l S 0 J 19.38 335.523 m 594.386 335.523 l S BT /F0 13 Tf 75.178 704.928 Td (LIMITED DURABLE POWER OF ATTORNEY \(LDPOA\) - PRE-RETIREMENT) Tj ET 0 J 18.723 673.866 m 593.728 673.866 l S 0 J 18.873 354.475 m 593.878 354.475 l S 0 J 19.026 352.990 m 594.031 352.990 l S 0 J 18.876 333.377 m 593.88 333.377 l S 0 J 19.035 332.552 m 594.040 332.552 l S BT /F0 10 Tf 21.94 340.826 Td (PART II - MEMBERS \(PRINCIPAL\) INFORMATION \(Type or Clearly Print This Information\)) Tj /F0 9 Tf -1.916 -95.590 Td (The individual you wish to designate as your Attorney-In-Fact \(Agent\)) Tj ET .75 w 0 J 74.778 57.31 m 190.403 57.31 l S 0 J 190.403 57.31 m 193.181 57.31 l S 0 J 279.326 57.31 m 298.8 57.31 l S BT /F0 10 Tf 19.757 58.558 Td (Directions:) Tj /F1 10 Tf ( ) Tj /F2 10 Tf (If you have not yet retired:) Tj /F1 10 Tf ( ) Tj ( Fill in and execute ) Tj (both) Tj ( pages of this LDPOA form and submit to your employing) Tj 0 -11.469 Td (agency.) Tj 0 -2.086 Td ET 1 w 0 J 18.218 673.041 m 593.223 673.041 l S BT /F0 10 Tf 20.571 573.746 Td ( ) Tj /F1 10 Tf ( 1) Tj /F0 10 Tf (. ) Tj /F1 10 Tf (This LDPOA gives the person you designate the power to make any and all decisions for your SERS related matters on) Tj 0 -11.469 Td ( your behalf. The RSD is providing this instrument to its SERS members as a matter of courtesy. Due to the significance) Tj 0 -11.469 Td ( of this document RSD ) Tj /F2 10 Tf (strongly recommends) Tj /F1 10 Tf ( that you seek legal advice before signing this document.) Tj /F0 10 Tf 0.156 -23.47 Td ( ) Tj /F1 10 Tf ( 2) Tj /F0 10 Tf (. ) Tj /F1 10 Tf (This LDPOA remains in effect until the earliest of the following occurs: \(a\) your death; \(b\) your Attorney-In-Fact) Tj 0 -11.469 Td ( relinquishes his/her duties or a court acting on your behalf terminates such authority; \(c\) you revoke this) Tj 0 -11.469 Td ( LDPOA by written notification to RSD. This LDPOA may not be amended.) Tj /F0 10 Tf 0 -32.55 Td ( ) Tj /F1 10 Tf ( 3) Tj /F0 10 Tf (. ) Tj /F1 10 Tf (If) Tj /F0 10 Tf ( ) Tj /F1 10 Tf (your Attorney-In-Fact is your spouse, RSD shall presume and deem this LDPOA revoked if either you or your spouse) Tj 0 -11.469 Td ( files for divorce unless you specifically write and notify us otherwise.) Tj /F0 10 Tf 0.156 -23.698 Td ( ) Tj /F1 10 Tf ( 4) Tj /F0 10 Tf (. ) Tj /F1 10 Tf (This LDPOA will continue in full force and effect despite any incapacity or disability you may suffer after execution.) Tj 0 -11.469 Td ( However, it is limited to pre-retirement transactions. If you wish it to continue post-retirement, you must execute another) Tj 0 -11.469 Td ( LDPOA for post-retirement transactions.) Tj /F0 10 Tf 0.156 -22.173 Td ( ) Tj /F1 10 Tf ( 5) Tj /F0 10 Tf (. ) Tj /F1 10 Tf (With) Tj /F0 10 Tf ( ) Tj /F1 10 Tf (the exception of a spouse, the Attorney-In-Fact listed on the LDPOA cannot also be your contingent annuitant or) Tj 0 -11.469 Td ( beneficiary unless you have specifically noted this on the form provided.) Tj 0 -2.086 Td ET 0 J 18.524 305.966 m 593.529 305.966 l S 0 J 19.344 280.037 m 594.349 280.037 l S 0 J 18.836 277.231 m 593.18 277.231 l S BT /F1 7 Tf 20.030 324.082 Td (MEMBER'S NAME \(Last\)) Tj ET 0 J 329.618 333.037 m 329.618 306.204 l S 0 J 451.378 332.875 m 451.378 306.043 l S BT 361.868 324.573 Td (EMPLOYEE NO.) Tj 100.638 -1.655 Td (SOC SEC NO.) 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Tj ET 0 J 406.437 241.055 m 405.777 191.103 l S BT 434.724 208.811 Td (RELATIONSHIP) Tj /F1 8 Tf -12.124 -123.843 Td (Date) Tj ET 0 J 412.503 93.5 m 515.940 93.5 l S BT /F1 10 Tf 19.528 127.593 Td (I have read or have had explained to me the information contained on this page, page one of this two page LDPOA form, and I) Tj 0 -11.469 Td (understand its contents. I understand that I am also referred to as the Principal in and throughout this document.) Tj ET 0 J 134.52 93.110 m 383.454 93.110 l S BT /F1 8 Tf 153.145 83.826 Td ( Name of Member \(Principal\)) Tj /F1 7 Tf 16.642 240.009 Td (First Name) Tj 125.56 -1.318 Td (M.I.) Tj -79.597 -89.855 Td (First Name) Tj 149.224 -0.238 Td (M.I.) 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My Attorney-In-Fact shall be) Tj 0 -11.469 Td (authorized to do the following with regard to my SERS pension benefits \(initial all that you ) Tj /F0 10 Tf (DO ) Tj /F1 10 Tf (authorize\):) Tj ET 1 w 0 J 19.363 290.475 m 268.296 290.475 l S 0 J 44.753 436.127 m 70.299 436.127 l S BT 84.226 621.34 Td (Talk to my employing Agency and Retirement Services Division staff about my benefit to learn and/or) Tj 0 -11.469 Td (receive the information necessary for retirement.) Tj -1.698 -92.375 Td (To make any and all designations concerning the method of payment of these sums, including the) Tj 0 -11.469 Td (designation of the address or bank account to which the benefits are sent or deposited.) Tj ET .75 w 0 J 152.986 484.761 m 166.876 484.761 l S BT 20.693 486.009 Td (I understand that SERS does ) Tj (not) Tj ( permit a non-spouse Attorney-In-Fact acting on behalf of a member to name themselves as a) Tj 0 -11.469 Td (beneficiary or contingent annuitant unless I specifically allow my Attorney-In-Fact to do so. By placing my initials \(not just a) Tj 0 -11.469 Td (check mark\) on the line next to the following statement, I agree and hold that:) Tj 57.498 -27.374 Td (To the extent that I could do so myself under SERS, and while it may be construed as self-dealing, my) Tj ET 1 w 0 J 208.236 422.09 m 389.755 422.09 l S BT 77.686 422.983 Td (non-spouse Attorney-In-Fact ) Tj /F0 10 Tf (\(name\) ) Tj /F1 10 Tf (may name himself or herself) Tj 0.159 -13.377 Td (as beneficiary or as a contingent annuitant with regard to any SERS related retirement benefit.) Tj -58.164 -15.854 Td (By signing this form. I am granting ) Tj /F0 10 Tf (\(name of Attorney-In-Fact\) ) Tj /F1 10 Tf (the full power and) Tj ET 0 J 178.756 391.377 m 366.225 391.377 l S 0 J 322.333 315.249 m 505.176 315.249 l S BT 20.188 375.925 Td (authority to act on my behalf with regard to the SERS transactions I have marked above. I understand the legal impact in) Tj 0 -11.469 Td (executing this LDPOA and hereby agree to hold the State of Connecticut and its employees harmless for any alleged misuse,) Tj 0 -11.469 Td (mismanagement or malfeasance by the Attorney-In-Fact exercising any and/or all powers granted under this LDPOA.) Tj 0 -11.469 Td (Furthermore, no State employee who relies in good faith upon the authority granted hereunder shall incur any liability to me, my) Tj 0 -11.469 Td (estate, my heirs, successors or assigns.) Tj 0.309 -13.748 Td (IN WITNESS WHEREOF, I have signed this Power of Attorney on) Tj ET 0 J 531.332 315.743 m 556.877 315.743 l S 0 J 397.327 76.459 m 422.872 76.459 l S BT /F0 10 Tf 20.188 258.982 Td (Statement of Witnesses:) Tj /F1 10 Tf ( I declare that the Principal has identified himself or herself to me, that the Principal signed or) Tj 0 -11.469 Td (acknowledged this LDPOA in my presence, that I believe the Principal to be of sound mind, that the Principal has affirmed that) Tj 0 -11.469 Td (the Principal is aware of the nature of the document and is signing it voluntarily and free from duress.) 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Tj -5.766 -18.658 Td ( Execute SERS retirement related forms, instruments and applications as appropriate.) Tj 0.156 -17.997 Td ( Designate beneficiaries and survivor annuitants in accordance with SERS statutes and procedures.) Tj 0.156 -18 Td ( Receive pre-retirement counseling on my behalf.) 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