Free 43567.pdf - Indiana

ACTIVE MEMBER DATA CHANGE
State Form 43567 (R7 /3-08) Approved by State Board of Accounts, 2008

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Website: www.in.gov/trf

PRIVACY NOTICE
Your TRF number is required on this form. Without it our agency cannot process your request. To obtain your number, feel free to call our office at (317) 232-3860 or toll free at (888) 286-3544.

PLEASE USE BLACK INK ONLY

MEMBER IDENTIFICATION
Full name of member Home telephone number ( ) Work telephone number ( ) TRF number (required) Email address Date of birth Marital status Married Gender Male Single Female

CHANGE OF ADDRESS
Old address (number and street) City State Zip code New address (number and street) City State Zip code

CHANGE OF BENEFICIARY
Primary beneficiary(s) ­ receive any remaining benefits in equal shares. Contingent beneficiary(s) ­ receive equal shares if the primary beneficiary predeceases the member. For each beneficiary named, please indicate primary or contingent in the appropriate box. Note: All previous designees will be deleted and replaced with your new selections. Your account will be edited to match what is listed below. For additional beneficiaries, please attach a sheet to this form and follow the same format as below. Full name of beneficiary #1 Social security number Date of birth Relationship Primary beneficiary Full name of beneficiary #2 Full name of beneficiary #3 Full name of beneficiary #4 Social security number Social security number Social security number Date of birth Date of birth Date of birth Relationship Relationship Relationship Contingent beneficiary Primary beneficiary Contingent beneficiary Primary beneficiary Contingent beneficiary Primary beneficiary Contingent beneficiary

MEMBER ATTESTS THAT ALL CHANGES ARE TRUE TO THE BEST OF HIS / HER KNOWLEDGE
Member signature (required) Date

NAME CHANGE AFFIDAVIT
Previous name (please print or type) New name (please print or type)

I, the undersigned, hereby affirm that there is no fraudulent intent in the decision to change my name. It is my wish that from this day forward, my retirement account at the Indiana State Teachers' Retirement Fund be maintained under the new name as listed above:

Member signature

Date

In lieu of this affidavit, one of the following documents may be submitted: A copy of your marriage certificate A copy of your divorce decree restoring your former name; or A copy of the court order whereby you have legally changed your name.

NOTARY PUBLIC CERTIFICATION (For name change only)
State of ____________________________ SS: County of __________________________ Before me the undersigned, A Notary Public for___________________________________ County, Officer's county of residence State of ______________________, personally appeared ___________________________________________. Name of person And they, being first duly sworn by me upon their oath, say that the facts alleged in the foregoing instrument are true. Signed and sealed this ______ day of ________________________, 200__. (Signature) _______________________________________ _______________________________________ Printed or typed name of officer My commission expires:_____________________ (SEAL)