Free 04717.pdf - Indiana

INDIANA STATE TEACHERS' RETIREMENT FUND

APPLICATION FOR WITHDRAWAL FROM THE FUND DUE TO DEATH OF MEMBER
State Form 4717 (R4 / 11-06) Approved by State Board of Accounts, 2006

150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Telephone: (317) 232-3860/ Toll Free: (888) 286-3544 Fax: (317)232-3882 Web: www.in.gov/trf

Privacy Notice
Your Social Security Number is being requested pursuant to IRS Code 3405. Disclosure is mandatory and this document cannot be processed without it.

An original Death Certificate is required to be submitted with this form.

MEMBER INFORMATION
Name of deceased member

Social Security number of deceased member

ISTRF number of deceased member

Date of birth of deceased member (month, day, year)

The undersigned for and on behalf of said decedent's estate does hereby apply for the payment of the amount paid into said Fund by said deceased teacher ­ less deductions, if any, to be made by law. The undersigned respectfully shows that ___________________________________________________ died (circle one) testate in testate

at ________________________________________________ in the County of ____________________________________________________________ and State of ______________________________________________ on ________________________________________, 20 ___________________________.

BENEFICIARY INFORMATION
Signature of beneficiary Address (number and street or P.O. box)

City

State

ZIP code

Date of birth (month, day, year)

Social Security number

NOTARY CERTIFICATE

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, says 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)