Free 53972.FH11 - Indiana

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APPLICATION FOR IRREVOCABLE VOLUNTARY WITHDRAWAL TO PURCHASE SERVICE CREDIT FROM ANOTHER GOVERNMENTAL RETIREMENT PLAN
State Form 53972 (6-09) Approved by State Board of Accounts, 2009

PUBLIC EMPLOYEES RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2899 Telephone: (317) 233-4162 Toll-free: (888) 526-1687 Local fax: (317) 234-5922 Toll-free fax: (866) 591-9441

* 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.

This form is completed only if you are withdrawing all or part of your Annuity Savings Account (ASA). A member may transfer the necessary amount from the member's ASA to purchase service credit in the Sheriffs Retirement Plan if all of the following conditions are met: 1. The member has not attained vested status (at least ten (10) years of PERF service), and 2. The member is no longer in a PERF-covered position, and 3. The member is currently in a position covered by the Sheriffs Retirement Plan, and 4. The member is transferring the funds to purchase service in the Sheriffs Retirement Plan. The MEMBER INFORMATION and MEMBER AFFIDAVIT sections must be completed. The MEMBER AFFIDAVIT section must be properly witnessed by a Notary Public. An authorized representative of the Sheriffs Retirement Plan must complete the PURCHASE VERIFICATION section. Return the completed, signed, and dated form to PERF at the above address. When your application has been approved by PERF, a check will be issued to the Sheriffs Retirement Plan. The check will be written utilizing the information provided in the PURCHASE VERIFICATION section of this form and mailed to the address provided on this form.

PART 1 - MEMBER INFORMATION
Social Security Number * Name of applicant (first, middle initial, last) Address (number and street, city, state, and ZIP code) Home telephone number Other telephone number E-mail address Date of birth (month, day, year)

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PART 2 - CURRENT EMPLOYER INFORMATION

Name of employer

Dates employed (month, day, year)

PART 3 - MEMBER AFFIDAVIT 1. 2. 3. I am not vested in PERF. I understand that, by completing this transfer: I am waiving all credit for service in PERF, this transfer is irrevocable, and any amount left in the Annuity Savings Account after the transfer to purchase service credit will remain subject to PERF provisions. Having been duly sworn on oath, I declare that all of the following apply: a. I am the individual applying for a transfer of my Annuity Savings Account to purchase service in the Sheriffs Retirement Plan, and b. I have personally prepared this application, and c. The information I have supplied is true to the best of my knowledge and belief.
Date (month, day, year)

Signature of applicant Printed name of applicant

PART 4 - CERTIFICATION OF NOTARY PUBLIC STATE OF ______________________________________ COUNTY OF _______________________________

SS: SEAL

Before me, the undersigned, a notary public, in and for the state and county above named, personally appeared ________________________________________________, being first duly sworn by me upon their oath, say that the facts alleged in the foregoing
Printed name of applicant

instrument are true. Signed and sealed on this ____________ day of _____________________________________, 20________.
Signature of notary public County of residence Printed name of notary public Date commission expires (month, day, year)

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PART 5 - VERIFICATION OF PURCHASE PERF, a qualified employer plan under Code section 401(a), requests the following verification: The ______________________________________________________________________________________________ has approved the request of
Printed name of governmental retirement plan (payee)

_______________________________________________________________________________ to purchase ____________ year(s) of service credit
Printed name of applicant Number of years

at a total cost of $ ________________________.
Total amount to be transferred Signature of authorized representative Printed name of authorized representative Date (month, day, year)

PART 6 - CERTIFICATION OF EMPLOYING OFFICIAL Employer - If this application has been forwarded to you, please complete this section of the application and return it to PERF. Thank you for your cooperation. I hereby certify that _________________________________________________, Social Security Number ____________________________________,
Printed name of employee Employees Social Security Number *

left service in a PERF-covered position on the ____________ day of _____________________________________, 20________.
Name of employer Signature of authorized representative Printed name of authorized representative Employer number Date (month, day, year) Telephone number of employer

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FOR OFFICE USE ONLY
Processed by: Date of payment (month, day, year) Audited by: Date (month, day, year)

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