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9996
Special Power of Attorney (POA) for PERS
Section B: Attorney-in-fact information
Section A: Applicant information
(Type or print clearly in dark ink. Illegible forms could be returned to you, which could delay your request.)
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Phone – 503-598-7377 toll free – 888-320-7377
Fax – 503-598-0561 website – http://oregon.gov/pers
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may
request help by calling 503-598-7377, toll free 888-320-7377, or TTY 503-603-7766.
Form #459-260 (10/17/2012) SL3 IIM Code:9996
Offi ce use only
PERS
OPSRP
IAP
Member
Alternate payee
Cross reference member SSN
First name MI Last name Social Security number*
Mailing address (street or PO box) PERS number (optional)
City State Zip Country Date of birth (mm-dd-yyyy)
Day phone number Evening phone number E-mail (optional)
*Providing your Social Security number (SSN) is voluntary. It will be used for con rmation purposes. If you choose not to supply your
SSN, it may take PERS staff longer to process your form.
If multiple attorney(s)-in-fact, check one: Either may sign or Both must sign
I, ________________________ (name of principal), grant the above named attorney(s)-in-fact power and authority
to act on my behalf in all matters associated with my Oregon Public Employees Retirement System (OPERS) bene ts
under ORS Chapter 238 and Chapter 238A that I would otherwise be able to perform myself, including changes of ben-
e ciary and changes of retirement option. This power of attorney may be
revoked at any time through a written noti cation by the principal delivered
The attorney(s)-in-fact May/ May not appoint and substitute for them-
selves any agent or attorney with the same authority as previously stated.
(This substitution may be revoked at any time.)
Principal’s signature (do not print) Date
Attorney-in-fact Co-attorney-in-fact
Name Name
Mailing address (street or PO box) Mailing address (street or PO box)
City State Zip City State Zip
Attorney-in-fact signature (do not print) Date Co-Attorney-in-fact signature (do not print) Date
1st alternate attorney-in-fact 2nd alternate attorney-in-fact
Name Name
Mailing address (street or PO box) Mailing address (street or PO box)
City State Zip City State Zip
1st alternate attorney-in-fact signature (do not print) Date 2nd alternate attorney-in-fact signature (do not print) Date
This document gives the person(s) you designate the power to make any and all decisions for your PERS-related mat-
ters on your behalf. This Power of Attorney takes effect on the date signed and supersedes any other POA on le with
PERS. It remains in effect until: 1) PERS or the attorney(s)-in-fact has/have actual knowledge of your death, 2) you
revoke the power of attorney, 3) your attorney-in-fact relinquishes his/her duties and position, or 4) a power of attorney
with a later date is received and accepted from you.
This form is for all PERS retirement programs. Call or visit our website if this is not the form you need.
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Oregon Special Power of Attorney for PERS Form
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