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APPLICATION FOR DIRECT DEPOSIT
State Form 47144 (R5 / 5-09) Approved by State Board of Accounts, 2009

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / Toll-free (888) 286-3544 Fax: (317) 232-3882 / E-mail: [email protected] Web site: www.in.gov/trf

PRIVACY NOTICE
Your Social Security number is being requested by this agency pursuant to the requirements of IRS Code 3405. This disclosure is mandatory and this form cannot be processed without this information

INSTRUCTIONS: Use black or blue ink only.

A trust is deemed to be in effect by the operation of this instrument in the periodic transfer of funds by the payor to the financial organization acting as trustee for the lifetime benefit of the payee to retain and to revert to the payor the funds transferred after the death of the payee. This instrument is governed by the Indiana law and enforceable under the jurisdiction of the State of Indiana.

AUTHORIZATION
Instead of receiving periodic recurring benefit payments by check from the Indiana State Teachers' Retirement Fund, I (payee) authorize and request TRF to direct the net amount of such recurring payments to my account at the financial organization (Bank) designated below, and I authorize said Bank to accept and to credit the payments to my account. I acknowledge that the transfer of the payments by TRF to the Bank be deemed complete satisfaction and discharge of the obligation of TRF due me. This authorization is not an assignment of my right to receive payment and revokes all prior payment direction notifications applicable to these payments. I will comply with the Bank's procedures providing safeguards against withdrawals of deposits after my death. If any deposits are made subsequent to my death to which I am not entitled, I hereby authorize and direct said Bank on behalf of my estate to refund said deposits to TRF and to charge same to my account. Full name of payee (printed) Social Security number TRF number Address City Are you receiving more than one monthly benefit check from TRF? Yes No Telephone number with area code State ZIP Code E-mail address

This is a new address

If so, do you want all TRF checks deposited into the same account? Yes No

If not, please complete another Application for Direct Deposit.

ACCOUNT INFORMATION
Please complete the following information and attach a voided check. Routing number (ABA number) Account number

Type of account

Savings

Checking Name, address, and telephone number of financial organization

List all names on the account

Signature of payee

Date signed (mm/dd/yyyy)