Free 17294.pdf - Indiana

INDIANA STATE TEACHERS' RETIREMENT FUND

AFFIDAVIT OF DISTRIBUTEE FOR DEATH BENEFIT OF DECEASED MEMBER
State Form 17294 (R5 / 12-07) Approved by State Board of Accounts, 2007

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.

The undersigned herewith make application for withdrawal from the Indiana State Teachers' Retirement Fund of the death benefit due in the account of:
Name of deceased member Social Security number of deceased member ISTRF number of deceased member Date of birth of deceased member (month, day, year)

whose death occurred ___________________________, 20_______ and respectfully state to the Board of Trustees of said Indiana State Teachers' Retirement Fund that they are the sole and only distributees entitled to receive the death benefit accrued in the account of said decedent in the Indiana State Teachers' Retirement Fund; and that a. no petition for the appointment of personal representative is pending or has been granted, and b. forty-five (45) days have elapsed since the death of the decedent, and c. the value of the gross probate estate, wherever located, less liens and encumbrances, does not exceed fifty thousand dollars ($50,000). This affidavit is filed under authority of the provisions of IC 29-1-8, as amended, providing for dispensing with administration of estates in certain cases.
Name Street address

City

State

Zip

Name

Street Address

City

State NOTARY CERTIFICATE

Zip

STATE OF _____________________________________________ SS: COUNTY OF ___________________________________________ Subscribed and sworn to me this _____________ day of __________________________ 20 ____________
Signature of applicant Signature of Notary Public

Applicant's Social Security number or EIN of the trust

Printed or typed name of Notary Public

Printed or typed name of applicant

County of residence

Date subscribed and sworn to (Notary Public) (month ,day, year)

Date commission expires (month, day, year)