Free 28105.FH11 - Indiana

PARTICIPATION ELECTION FOR SCHOOL CORPORATION EMPLOYEES
State Form 28105 (R2 / 11-08)

PUBLIC EMPLOYEES RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2899

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* This agency is requesting disclosure of Social Security Numbers in accordance with Internal Revenue Code; disclosure is mandatory and this form will not be processed without it.

NOTICE: If employees who are currently having deductions made from their compensation for PERF coverage believe that they are not legally required to be members of PERF, they should notify PERF immediately by writing to the address above.
Name of employee (first, middle initial, last) Social Security Number * Date of hire (month, day, year)

Name of employer

Account number of employer

I was hired on the above date and am employed by a participating school corporation. I occupy a PERF-covered position normally requiring performance of services of more than six hundred (600) and less than one thousand (1000) hours a year and I hereby elect to become a member of the Public Employees Retirement Fund of Indiana pursuant to IC 5-10.3-7-3 (c). This election is not revocable. This election shall not entitle me to credit for service prior to the date of July 1, 1986, or the date this form is signed, whichever is later. I am not a member of, eligible to be a member of, or will become eligible by reason of employment to be a member of any other pension or retirement funds or plans, except the federal Social Security program, maintained in whole or in part by appropriations by the state of Indiana or a political subdivision of the State of Indiana. I affirm, under the penalties for perjury, that the foregoing representations are true.
Signature of employee Date (month, day, year)