Forms

City of Los Angeles DC Plan

Forms

Forms are provided in this section as viewable files that can be printed. Forms cannot be completed online because they must be filled out, signed and, in some cases notarized, before they can be accepted by the Plan.

The Unforeseeable Emergency Withdrawal Application is available as a prefilled form. The prefilled form may be accessed at menu option Account, Withdrawals, Request a Withdrawal.

To view the desired package or form, simply click on the title in the following list:

Rollover/Plan Transfer Contribution Form

Roth In-Plan Conversion Form

Accrued Leave Deferral Option Form

Catch-Up Contribution Form

Leave of Absence Loan Payment Change Request

Loan Offset Request Form

Loan Payment Request Form

Purchase of Service Credits Request Form

Retired/Terminated Participant Loan Application

Eligible Retired Public Safety Officers Special Election Form and Distribution Request

Special Tax Notice

Beneficiary Designation Form

Installment Form

Active Participant Loan Application

Distribution Request Form

Brokerage Delivery Instruction Form

Direct Deposit Agreement form

Retired/Terminated Participant Loan Payment Authorization Form

Birth or Adoption Withdrawal Form

Qualified Disaster Repayment Form

Formulario de Designaci n del Beneficiario

Formulario de Distribuci n

Formulario de Inscripci n

Repayment Request for Qualified Birth or Adoption Withdrawal