HURRICANE KATRINA SPECIAL DISTRIBUTION RECEIPT AND RELEASE AGREEMENT Before me, the undersigned Notary Public, on this ______ day of __________________, 200___, personally came and appeared: ____________________________ Print or type name of Affiant ______________________ Social Security Number
Who, after first being duly sworn, did declare and say that: 1. I am a member of the Louisiana School Employees’ Retirement System and have read the information contained in the attached sheet entitled “Tax Favored Treatment for Qualified Hurricane Katrina Distributions” and that I meet the qualifications required of the Act. 2. I am of the full age of majority, and am competent. 3. I further acknowledge that funds are not being withheld from the distribution for income taxes and that I will be responsible for payments of any taxes due on the money that I am receiving as a refund of my accumulated contributions, or from my DROP/IBRP Account. 4. I understand that R.S. 11: 1115 provides that membership in this system ceases when a member withdraws his accumulated contributions from LSERS, and further provides that an acceptance of a refund of accumulated contributions automatically cancels all rights that I may have in the system. 5. I have requested this distribution freely and intentionally, and understand the full ramifications of my accepting said distribution.
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(Member Initials)
6. I further declare that by accepting payment of the distribution, I do hereby release from any liability, and indemnify and holds harmless LSERS, its executive officers, employees, and Trustees from any, and all, past, present, and/or future claims, actions, demands, rights, damages, causes of action and rights of action whatsoever, known and unknown, anticipated and unanticipated, in any way resulting from and/or as a result of my acceptance of said distribution. THUS DONE AND PASSED on the _____ day of ___________, 200__at _____________________, in the state of ________________________, in the presence of me, Notary after due reading of the whole.
__________________________________ Member
__________________________________ Notary Public, No.