Free 49518.pdf - Indiana

APPLICATION FOR RETIRED MEMBER CHANGE OF BENEFICIARY/SURVIVOR BENEFICIARY AND/OR RETIREMENT OPTION
State Form 49518 (R4 / 7-07) Approved by State Board of Accounts, 2007

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Home page: http://www.in.gov/trf PRIVACY NOTICE
Your Social Security number is requested by this agency in accordance with the requirements of IRS Code 3405. Disclosure is mandatory; this form will not be processed without this information.

PRIVACY NOTICE

PART 1:

RETIRED MEMBER INFORMATION
TRF number Social Security number

Name of retired member (first, middle, last)

Full address (number and street or P.O. Box, city, state, and ZIP code)

Area code and telephone number

Date of birth (month, day, year)

(

)

YES

Is this a new address?

PART 2:

REELECTION OF BENEFITS

Please be sure to mark your selection "Yes" or "No" for the A-4 option (Social Security integration) if you are under age 62. If "Yes", you must enclose a copy of your Social Security Estimate.

A-2 Straight life without a guaranteed period Yes No With A-4

B-1 100% Survivorship With A-4

Yes

No

B-2 66 2/3% Survivorship Yes With A-4 B-3 50% Survivorship With A-4

No

Yes

No

IF YOU HAVE SELECTED ANY OF THE "B" OPTIONS, YOU MUST DESIGNATE A SURVIVOR BENEFICIARY IN THE SPACE THAT FOLLOWS AND PROVIDE A COPY OF THE SURVIVOR BENEFICIARY'S BIRTH CERTIFICATE.
Name of survivor beneficiary Date of birth Social Security number

Full address (number and street or P.O. Box, city, state, and ZIP code)

TRF number (if survivor beneficiary is a member)

Relationship

IF YOU WANT A LUMP SUM PAYMENT WHICH MIGHT BE DUE AT YOUR DEATH TO GO TO SPECIFIC BENEFICIARIES RATHER THAN TO YOUR ESTATE, PLEASE SELECT BENEFICIARIES BELOW.
Name of beneficiary Primary Secondary Social Security number Name of beneficiary Primary Secondary Social Security number

Full address (number and street or P.O. Box, city, state, and ZIP code)

Date of birth

Full address (number and street or P.O. Box, city, state, and ZIP code)

Date of birth

Relationship

Relationship

Name of beneficiary Primary Secondary

Social Security number

Name of beneficiary Primary Secondary

Social Security number

Full address (number and street or P.O. Box, city, state, and ZIP code)

Date of birth

Full address (number and street or P.O. Box, city, state, and ZIP code)

Date of birth

Relationship

Relationship

Name of beneficiary Primary Secondary

Social Security number

Name of beneficiary Primary Secondary

Social Security number

Full address (number and street or P.O. Box, city, state, and ZIP code)

Date of birth

Full address (number and street or P.O. Box, city, state, and ZIP code)

Date of birth

Relationship

Relationship

PART 3: NOTARIZATION

I swear that I am the above named applicant; and that I have carefully read the questions and answers thereto and understand the same; that each answer is full, complete and true; no material fact has been concealed or omitted therefrom; and that said answers are made for presentation to the Board of Trustees of the Indiana State Teachers' Retirement Fund in making claim for a retirement benefit that may be payable to me under Indiana Code, section 5-10.2 and Indiana Code, section 5-10.4. I hereby revoke all beneficiaries and/or retirement options previously selected by me, and hereby select the above beneficiary designations and/or retirement option. I affirm that I am not otherwise prohibited from making such changes by any court order, decree, or agreement. I have furnished all necessary documentation (marriage license, death certificate of first spouse, or final divorce order or decree, and proof of birth for the newly named survivor beneficiary as required. I understand that any modifications in either my retirement option or beneficiary designation may result in a significant change in my monthly benefit. I agree to indemnify, defend, and hold harmless the Fund and its agents, officers, and employees from all claims and suits including court costs, attorney's fees, and other expenses arising from or caused by any misrepresentation made by me herein. I affirm, under the penalties for perjury, that the foregoing representations are true. Signed: _________________________________ Printed _________________________________ ISTRF Acct. #: _____________________________ Date: ____________________________________

Address:__________________________________________________________________________________________________________ State of ______________________________; SS County of _____________________________; Subscribed and sworn to, before me, a Notary Public, on this _________ day of ____________, 20______. Notary Public Signature:__________________________________________ Notary Public Printed:____________________________________________ SEAL Notary County of Residence:_______________________________________ My Commission expires:__________________________________________