Form Msd61 - Affidavit Of Natural Tutorship Of Minor Child
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1Form MSD61
R112011
AFFIDAVI
DO NOT FAX FORM
PRINT ALL INFORMATION
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Affidavit of Natural Tutorship of Minor Child
Deceased Member's First Name
Middle Name
Last Name
Deceased Member's SSN
SECTION 1: MINOR CHILD'S INFORMATION
Minor Child's First Name
Middle Name
Last Name
Minor Child's Social Security Number
Birth Date
Male
Female
SECTION 2: NATURAL TUTOR'S INFORMATION
Natural Tutor's First Name
Middle Name
Last Name
Natural Tutor's Social Security Number
Mailing Address
City
State
Zip Code
Daytime Area Code/Phone Number
Evening Area Code/Phone Number
E-mail Address
SECTION 3: NATURAL TUTOR'S CERTIFICATION AND AUTHORIZATION
I attest that I am the natural tutor and have custody of the above named minor child who is a surviving beneficiary of the above named
deceased member. I certify that I will be a prudent administrator of any funds issued for the benefit of the said minor.
Natural Tutor's Signature
Date
SECTION 4: NOTARIZATION
SWORN TO AND SUBSCRIBED BEFORE ME, Notary Public, in and for the state of _____________________, parish/county of_______________,
this _______ day of ________, 20____.
____________________________________
_______________________________________
Notary Public (Signature)
Notary ID # or Bar Roll #
____________________________________
_______________________________________
Notary Public Name
Commission Expires
(affix seal here)
Reset Form
MSD61 R
RETAIN A COPY FOR YOUR RECORDS
AFFIDAVI Page 1 of 1
112011
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Parent category: Legal