Limited Durable Power of Attorney Form - Connecticut
Power of Attorney - Pre Retirement
State Employees Retirement System
NEW CO-1049 Page 1 of 2
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
PART I - GENERAL INFORMATION AND INSTRUCTIONS - PLEASE READ CAREFULLY
Connecticut statutes allow an entity to establish its own criteria as to what it will accept with regard to a LDPOA. In order to
safeguard the interests of members of the State Employees' Retirement System ("SERS") a member wishing to designate
someone as his or her Attorney-In-Fact must use this form to do so. This LDPOA authorizes your Attorney-In-Fact to perform on
your behalf any transactions with SERS that you could request yourself. This form is intended for use with SERS only. Every
LDPOA is subject to review and approval by SERS. This two page document must be signed, dated, witnessed and
notarized where indicated.
LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - PRE RETIREMENT
PART II - MEMBERS (PRINCIPAL) INFORMATION (Type or Clearly Print This Information)
The individual you wish to designate as your Attorney-In-Fact (Agent)
Directions: If you have not yet retired: Fill in and otherwise execute both pages of this LDPOA form and send or give to your
employing agency. Your agency will forward the original LDPOA (both pages) with any relevant or necessary documentation to
the Retirement Services Division, 55 Elm Street, Hartford, CT., 06106.
Date
1. This document gives the person you designate the power to make any and all decisions for your SERS related matters on
your behalf. SERS is providing this instrument to its members as a matter of courtesy: due to the significance of this
document SERS strongly recommends that you seek legal advice before signing this document.
2. This document remains in effect until the earliest of the following occurs: (a) a period of five years from the date it is
signed; (b) SERS has knowledge of your death; (c) your Attorney-In-Fact relinquishes his/her duties or a court acting on
your behalf terminates such authority; (d) you revoke this LDPOA by written notification to SERS. This LDPOA may not
be amended.
3. If your Attorney-In-Fact is your spouse, SERS shall presume and deem this LDPOA revoked if either you or your spouse
files for divorce unless you specifically write and notify us otherwise.
4. This LDPOA presumes you are of sound mind when you execute it. It will continue despite any incapacity or disability you
may suffer after execution. However, it is limited to a period of five years from the date of your signature. If you wish it to
continue after five years, you must execute another LDPOA.
5. With the exception of a spouse, the "Attorney-In-Fact" listed on the POA cannot also be your contingent annuitant or
beneficiary unless you have specifically noted this on the form provided.
MEMBER'S NAME (Last, First, M.I.)
EMPLOYEE NO.
SOC SEC NO.
MEMBER'S ADDRESS (Street, No., Name)
(City, State, Zip Code)
PART III - DESIGNATION OF ATTORNEY- IN-FACT (AGENT) (Type or Clearly Print This Information)
PART IV - AGREEMENT AND ACKNOWLEDGEMENT
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
understand its contents. I understand that I am also referred to as the Principal in and throughout this document.
NAME (Last, First, M.I.)
ADDRESS (Street, No., Name)
(City, State, Zip Code)
SOC SEC NO.
(Print Clearly or Type)
RELATIONSHIP
Name of Member (Principal)
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