Application For Alternate Payee Benefits Pursuant To A Qualified Domestic Relations Order - Massachusetts Laborers' Annuity Fund Page 2
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3Massachusetts Laborers’ Annuity Fund
14 New England Exec. Park, Burlington, MA 01803
Tel: 781-272-1000 Fax: 781-272-2226
INSTRUCTIONS: Please read and complete this application carefully. Return it to the Fund Office
along with a copy of your proof of age, Social Security card, and Photo ID.
Application for Alternate Payee Benefits
Pursuant to a Qualified Domestic Relations Order
1. MEMBER INFORMATION:
a. Name: ____________________________
b. Social Security No.______________________
c. Date of Birth: _______________ d. Date of Divorce: ___________ e. Local Union #:_________
2. APPLICANT INFORMATION:
a. Your Name: ____ __________________________________
b. Your address:________________________ ___ ______________________________________
Mailing address
Street
City
State
Zip Code
c. Your Telephone No: ________________________ d. Your date of birth:___________________
Area code-number
(Attach Proof of Age) month-day-yr.
e. Social Security No.:
____________________ Include a copy of your social security card.
3. Form of Payment
___ a. Lump Sum (May include Rollover to IRA) All:
(check) or Amount: $__________
____ b. Monthly Installments- You may elect to receive benefits in approximately equal monthly installments
over a period not to exceed 15 years. Indicate the number of installments___________
___ c. Combination Payment and Installments—You may elect to receive a portion of your account, with the
balance paid out in approximately equal monthly installments, not to exceed 15 years. If you choose this
method, indicate the portion you wish to receive at this time:____________ and the
number of monthly installments for the balance of the account:___________.
4. Signature: I hereby apply for an Alternate Payee Annuity, as provided for under in the Qualified
Domestic Relations Order, from the Massachusetts Laborers’ Annuity Fund. I certify that the
statements made in this application are true to the best of my knowledge and belief. I understand that
a false statement shall be sufficient reason for the denial, suspension, or discontinuance of benefits and
that the Trustees shall have the right to recover any payments made to me in reliance of such false
statement.
_________________________________
_________________
Date
Signature of Applicant
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