Form PERS-OSS-138 "Special Power of Attorney" - California

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What Is Form PERS-OSS-138?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the California Public Employees' Retirement System;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PERS-OSS-138 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS-OSS-138 "Special Power of Attorney" - California

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Special Power of Attorney
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Creation of Durable Power of Attorney for Retirement-Related Business
Section 1
When completing this form,
Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
please be sure to print the
requested information.
Address
County
For the purpose of this
(
)
form, a “principal” is
City
State
ZIP
Daytime Phone
defined as a person who
By this document I intend to create a power of attorney by appointing the person(s) named below to make
empowers another to act
retirement-related decisions for me as allowed by the California Probate Code. The authority granted
as a representative on
pursuant to this power of attorney is expressly limited to decisions relating to my financial and health
his or her behalf.
benefits under the California Public Employees’ Retirement System, the Judges’ Retirement System I or the
The “agent” is the
Judges’ Retirement System II, and the Legislators’ Retirement System, hereinafter CalPERS, JRS I, JRS II,
attorney-in-fact.
and LRS, respectively. I give my agent, also called an attorney-in-fact, the powers specified herein with
the understanding that these powers will be used for my benefit and will be exercised only in a fiduciary
capacity. This power does not authorize the appointed agent to make any medical decisions for me.
Designation of Attorney-in-Fact (Agent)
Section 2
You have the option to designate one attorney-in-fact.
If you appoint more than
one attorney-in-fact and do
If you appoint more than one attorney-in-fact, choose the jointly, separately, or alternately check box below:
not check a box, all of your
Jointly
– All designated attorneys-in-fact must sign for any action. Granting joint authority to two or
attorneys-in-fact must act
c
or sign together (jointly).
more attorneys-in-fact means that the agents’ authority is exercisable only by their unanimous action.
If one is unavailable because of absence, illness, or other temporary incapacity, the other attorneys-in-
fact may exercise their authority under the power of attorney.
Separately
– Any one designated attorney-in-fact may act without the other(s).
c
– Your attorney-in-fact will act in the numerical order you assign in the boxes below.*
Alternately
*If you choose “Alternately,”
c
identify the order of
The successor attorney-in-fact will act if the person you originally appointed is unavailable because
your attorneys-in-fact in
of absence, illness, or other temporary incapacity. Delegation of powers to any third party who is not
the boxes below.
named as an alternate attorney-in-fact is not permitted under this document.
#
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Relationship
Address
Social Security Number or CalPERS ID
(
)
City
State
ZIP
Daytime Phone
#
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Relationship
Address
Social Security Number or CalPERS ID
(
)
City
State
ZIP
Daytime Phone
#
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Relationship
Address
Social Security Number or CalPERS ID
(
)
City
State
ZIP
Daytime Phone
PERS-OSS-138 (9/17)
Page 1 of 5
Special Power of Attorney
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Creation of Durable Power of Attorney for Retirement-Related Business
Section 1
When completing this form,
Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
please be sure to print the
requested information.
Address
County
For the purpose of this
(
)
form, a “principal” is
City
State
ZIP
Daytime Phone
defined as a person who
By this document I intend to create a power of attorney by appointing the person(s) named below to make
empowers another to act
retirement-related decisions for me as allowed by the California Probate Code. The authority granted
as a representative on
pursuant to this power of attorney is expressly limited to decisions relating to my financial and health
his or her behalf.
benefits under the California Public Employees’ Retirement System, the Judges’ Retirement System I or the
The “agent” is the
Judges’ Retirement System II, and the Legislators’ Retirement System, hereinafter CalPERS, JRS I, JRS II,
attorney-in-fact.
and LRS, respectively. I give my agent, also called an attorney-in-fact, the powers specified herein with
the understanding that these powers will be used for my benefit and will be exercised only in a fiduciary
capacity. This power does not authorize the appointed agent to make any medical decisions for me.
Designation of Attorney-in-Fact (Agent)
Section 2
You have the option to designate one attorney-in-fact.
If you appoint more than
one attorney-in-fact and do
If you appoint more than one attorney-in-fact, choose the jointly, separately, or alternately check box below:
not check a box, all of your
Jointly
– All designated attorneys-in-fact must sign for any action. Granting joint authority to two or
attorneys-in-fact must act
c
or sign together (jointly).
more attorneys-in-fact means that the agents’ authority is exercisable only by their unanimous action.
If one is unavailable because of absence, illness, or other temporary incapacity, the other attorneys-in-
fact may exercise their authority under the power of attorney.
Separately
– Any one designated attorney-in-fact may act without the other(s).
c
– Your attorney-in-fact will act in the numerical order you assign in the boxes below.*
Alternately
*If you choose “Alternately,”
c
identify the order of
The successor attorney-in-fact will act if the person you originally appointed is unavailable because
your attorneys-in-fact in
of absence, illness, or other temporary incapacity. Delegation of powers to any third party who is not
the boxes below.
named as an alternate attorney-in-fact is not permitted under this document.
#
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Relationship
Address
Social Security Number or CalPERS ID
(
)
City
State
ZIP
Daytime Phone
#
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Relationship
Address
Social Security Number or CalPERS ID
(
)
City
State
ZIP
Daytime Phone
#
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Relationship
Address
Social Security Number or CalPERS ID
(
)
City
State
ZIP
Daytime Phone
PERS-OSS-138 (9/17)
Page 1 of 5
Put your name and Social
Security number or CalPERS ID
Name of Member
Social Security Number or CalPERS ID
at the top of every page
General Statement of Authority Granted
Section 3
I hereby grant to my attorney-in-fact full power and authority to transact matters on my behalf relating to
You must check a box
to indicate whether
CalPERS, JRS I, JRS II, or LRS. I understand that I am granting authority to the attorney-in-fact regardless
you are granting the
of whether that person is related to me by blood, marriage, or legal domestic partnership. By signing this
specific authority to your
Special Power of Attorney form I intend that:
attorney(s)-in-fact. If you
My attorney-in-fact (
is;
is not) authorized to select any retirement payment option available
do not check a box, your
c
c
attorney(s)-in-fact will
under the retirement plan other than the Unmodified Allowance.
not be granted this
Note: Allowing your attorney-in-fact to choose any retirement payment option available under
specific authority.
the retirement plan other than the Unmodified Allowance may reduce the monthly allowance
that would otherwise be paid to you during your lifetime.
See A Guide to the
CalPERS Special Power of
My attorney-in-fact (
is;
is not) authorized to designate or change my beneficiary.
c
c
Attorney (PUB 30) for a
– My attorney-in-fact (
is;
is not) authorized to designate him or herself as my beneficiary.
c
c
detailed explanation of the
authority you are granting.
On the following lines you may give special instructions limiting the powers granted to your
attorney(s)-in-fact.
Duration of Power of Attorney
Section 4
Unless I indicate otherwise, this power of attorney shall be considered effective immediately and will
Please be careful in
choosing when you
continue for the duration specified below or, if no duration is specified, until my death. My attorney-in-fact
want your power of
is hereby instructed to notify CalPERS in writing of my disability, incapacity, or death immediately upon
attorney to commence
its occurrence. I understand that I may revoke this power of attorney at any time by providing CalPERS
and/or terminate.
with a written statement of my intent to do so.
Check one box to
This durable power of attorney is to commence immediately and to remain in effect for my lifetime,
c
indicate your choice.
even if I become incapacitated, or until I specifically revoke it.
Checking multiple boxes
This limited power of attorney is to commence on _________________ and terminate on
c
may invalidate this form.
Date (mm/dd/yyyy) or Event
______________________________.
The person that you
Date (mm/dd/yyyy) or Event
authorize to make
the determination of
This contingent/springing power of attorney is to commence only upon a determination that
c
incapacity must be at least
18 years old at the time
I am incapacitated and/or unable to handle my own affairs. The determination of whether I am
of designation. This person
incapacitated and/or unable to handle my own affairs for the purpose of this instrument shall
may be, but is not required
be made in a written statement signed by
to be, a licensed
physician or attorney.
______________________________________________________.
Name and Relationship or Title of Person Authorized to Make the Determination
This general (non-durable) power of attorney is to terminate in its entirety if I become incapacitated.
c
The determination that I am incapacitated and/or unable to handle my own affairs for the purpose
of this instrument shall be made in a written statement signed by
______________________________________________________.
Name and Relationship or Title of Person Authorized to Make the Determination
PERS-OSS-138 (9/17)
Page 2 of 5
Put your name and Social
Security number or CalPERS ID
Name of Member
Social Security Number or CalPERS ID
at the top of every page
Warning Statements
Section 5
The authority granted by the CalPERS Special Power of Attorney form is limited to matters relating
Attorney(s)-in-fact may
not conduct business by
to CalPERS, JRS I, JRS II, and LRS. The person designated as your attorney-in-fact does not have any
accessing your online
authority over your other real and/or personal property. If you wish that your attorney-in-fact have authority
my|CalPERS account.
over your real and/or personal property, it is recommended that you seek legal counsel.
All contact with CalPERS
on your behalf must be
You may notice that the language contained in the following Warning Statements refers to more
made by telephone, by
extensive authority than granted by the CalPERS Special Power of Attorney form. These Warning
written correspondence,
Statements are required by Probate Code section 4128 and must be included in all preprinted
or by visiting a
durable power of attorney forms even though the CalPERS Special Power of Attorney form does
Regional Office.
not authorize your attorney-in-fact to do many of the things mentioned in the Warning Statements.
The “agent” is the
If you are concerned with the Warning Statements or the extent of the authority being granted by
attorney-in-fact.
the CalPERS Special Power of Attorney form, we again recommend that you seek legal counsel.
(Warning): Notice to Person Executing Durable Power of Attorney
A durable power of attorney is an important legal document. By signing a durable power of attorney,
you are authorizing another person to act for you, the principal. Before you sign this durable power
of attorney, you should know these important facts:
Your agent (attorney-in-fact) has no duty to act unless you and your agent agree otherwise
in writing.
This document gives your agent the powers to manage, dispose of, sell, and convey your real and
personal property, and to use your property as security if your agent borrows money on your behalf.
This document does not give your agent the power to accept or receive any of your property, in
trust or otherwise, as a gift, unless you specifically authorize the agent to accept or receive a gift.
Your agent will have the right to receive reasonable payment for services provided under this
durable power of attorney unless you state otherwise in this power of attorney.
The powers you give your agent will continue to exist for your entire lifetime, unless you state
that the durable power of attorney will last for a shorter period of time or unless you otherwise
terminate the durable power of attorney. The powers you give your agent in this durable power
of attorney will continue to exist even if you can no longer make your own decisions regarding
the management of your property.
You can amend or change this durable power of attorney only by executing a new durable power
of attorney or by executing an amendment through the same formalities as an original. You have
the right to revoke or terminate this power of attorney at any time as long as you are competent.
This durable power of attorney must be dated and must be acknowledged before a notary
public or signed by two witnesses. If it is signed by two witnesses, they must witness either
(1) the principal’s signing of the power of attorney or (2) the principal’s acknowledgement of his
or her signature. A durable power of attorney that may affect real property should be acknowledged
before a notary public so that it can easily be recorded.
You should read this durable power of attorney carefully. When effective, this durable power of
attorney will give your agent the right to deal with property that you now have or might acquire
in the future. This durable power of attorney is important to you. If you do not understand the
durable power of attorney or any provision of it, you should obtain the assistance of an attorney
or other qualified person.
PERS-OSS-138 (9/17)
Page 3 of 5
Put your name and Social
Security number or CalPERS ID
Name of Member
Social Security Number or CalPERS ID
at the top of every page
Warning Statements, Continued
Section 5, continued
(Warning): Notice to Person Accepting the Appointment as Attorney-in-Fact
By acting or agreeing to act as the agent (attorney-in-fact) under this power of attorney you assume
the fiduciary and other legal responsibilities of an agent. These responsibilities include:
The legal duty to act solely in the interest of the principal and to avoid conflicts of interest.
The legal duty to keep the principal’s property separate and distinct from any other property
owned or controlled by you.
You may not transfer the principal’s property to yourself without full and adequate consideration or
accept a gift of the principal’s property unless this power of attorney specifically authorized you to
transfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s
property to yourself without specific authorization in the power of attorney, you may be prosecuted
for fraud and/or embezzlement. If the principal is 65 years of age or older at the time the property
is transferred to you without authority, you may also be prosecuted for elder abuse under Penal
Code section 368. In addition to criminal prosecution, you may also be sued in civil court.
I have read the foregoing notice and I understand the legal and fiduciary duties that I assume by
acting or agreeing to act as the agent (attorney-in-fact) under the terms of this power of attorney.
Lastly, the principal’s benefit shall not be subject to execution, process, or assignment under California
Public Employees’ Retirement Law section 21255.
Signature of the agent
Print Name of Agent (First Name, Middle Initial, Last Name)
(attorney-in-fact)
is optional.
Signature of Agent
Date (mm/dd/yyyy)
Print Name of Agent (First Name, Middle Initial, Last Name)
Signature of Agent
Date (mm/dd/yyyy)
Print Name of Agent (First Name, Middle Initial, Last Name)
Signature of Agent
Date (mm/dd/yyyy)
Principal’s Acknowledgement and Execution
Section 6
I am of sound mind and have consulted with an attorney or otherwise understand my elections. I am
To be completed and
signed by the principal.
executing this legal document under my own free will. I agree that any third party who receives a copy
of this document may act under it. Revocation of the power of attorney is not effective as to a third party
until the third party has actual knowledge of the revocation.
Date Executed (mm/dd/yyyy)
City
State
Signature of Principal
County
Print Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
PERS-OSS-138 (9/17)
Page 4 of 5
Put your name and Social
Security number or CalPERS ID
Name of Member
Social Security Number or CalPERS ID
at the top of every page
Witness Information
Section 7
I have witnessed the principal’s signature or the principal’s acknowledgment of his or her signature
Must be completed by
two individuals who are
designating power of attorney. I am of sound mind, I am an adult at least 18 years old, and I am not the
at least 18 years of
attorney-in-fact or successor attorney-in-fact. My signature certifies that the principal is known to me
age and are not named
and is the same person who signed and dated this Special Power of Attorney form.
as attorney-in-fact or
successor attorney-in-fact.
Signature of Witness 1
Print Name of Witness 1 (First Name, Middle Initial, Last Name)
Alternately, Section 8
below must be completed
Address
Date (mm/dd/yyyy)
by a notary public.
City
State
ZIP
Signature of Witness 2
Print Name of Witness 2 (First Name, Middle Initial, Last Name)
Address
Date (mm/dd/yyyy)
City
State
ZIP
Notary Public Acknowledgement
Section 8
Must be completed by
a notary public if Section 7
A notary public or other officer completing this certificate verifies only the identity of the individual
is not completed.
who signed the document to which this certificate is attached, and not the truthfulness, accuracy,
or validity of that document.
CalPERS images these
documents. Please be
Notary
advised embossed seals
may not appear when this
document is reviewed. An
State
County
inked stamp is preferred.
On _______________ before me ____________________________________, personally appeared
Date (mm/dd/yyyy)
Printed Name of Notary Public
____________________________________, who proved to me on the basis of satisfactory evidence
Name of Principal
to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/
their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted,
executed the instrument. I certify under Penalty of Perjury under the laws of the State of California that
the foregoing paragraph is true and correct.
Witness my hand and official seal.
Signature of Notary Public
Notary Seal
Print Name
Mail to:
CalPERS Benefit Services Division • P.O. Box 942716, Sacramento, California 94229-2716
PERS-OSS-138 (9/17)
Page 5 of 5
Page of 6