Free 51003.pdf - Indiana

APPLICATION FOR ROLLOVER ACCOUNT
State Form 51003 (R / 8-08)

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* PRIVACY NOTICE All Social Security Numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory; this form will not be processed without the information

INSTRUCTIONS: 1. Please TYPE or PRINT. Use black ink. 2. Return the completed form directly to PERF. Do not return the instruction pages.

STEP 1: Member Information
Social Security Number * Date (month, day, year)


First name Address (number and street) Middle initial Last name


City Home telephone number State Other telephone number ZIP code

( )
E-mail address

(

)

STEP 2: Rollover Account Investment Directions ­ All investment choices in this box must total 100%.
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Money Market Fund Bond Fund S&P 500 Index Fund US Small Companies Stock Fund International Equity Index Fund

I revoke any previous investment directions for my rollover account and hereby direct the above investments, effective this date. I understand that these choices do not apply to the investment of my annuity savings account.
Signature of member Date (month, day, year)

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APPLICATION FOR ROLLOVER ACCOUNT (continued)
State Form 51003 (R / 8-08)

Name of member (last, first, middle initial)

Social Security Number

STEP 3: Beneficiary Information (Attach additional copies of this page if necessary.) Additional pages are attached. Yes No

Primary Beneficiary or Beneficiaries
Name of beneficiary (last, first, middle) Date of birth (month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code


Name of beneficiary (last, first, middle) Date of birth (month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code


Contingent Beneficiary or Beneficiaries
Name of beneficiary (last, first, middle) Date of birth (month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code


Name of beneficiary (last, first, middle) Date of birth (month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code



In accordance with the provisions of Indiana Code § 5-10.2-3, I designate my beneficiary or beneficiaries for my rollover account as shown above. I understand that this designation of beneficiary supersedes and replaces any prior designation of beneficiary or beneficiaries for my rollover account that may have been made. If the primary beneficiary or beneficiaries herein designated survive me, they shall receive the funds, if any, that are payable by the fund to a designated beneficiary. If the primary beneficiary or beneficiaries do not survive me, then the contingent beneficiary or beneficiaries shall receive such funds. If none survive me, then the beneficiary shall be my estate. I reserve the right to change the primary or contingent beneficiaries at any time prior to distribution of my rollover account by filing a Change of Beneficiary form with the Board of Trustees of the Fund. Such a change must be received and accepted by the fund for it to become effective.
Signature of member Printed name Date (month, day, year)

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APPLICATION FOR ROLLOVER ACCOUNT (continued)
State Form 51003 (R / 8-08)

Name of member (last, first, middle initial)

Social Security Number

STEP 4: Certification by Plan Administrator or Financial institution
Please select one of the following. I certify that the amount being transferred is an eligible rollover distribution as defined by the Internal Revenue Code and is form a source listed below: A qualified plan described in Section 401(a) or 403(a) of the Internal Revenue Code. An annuity contract or account described in Section 403(b) of the Internal Revenue Code. An eligible plan maintained by a state, political subdivision of a state, or an agency or instrumentality of a state or political subdivision of a state under Section 457(b) of the Internal Revenue Code. An individual retirement account (IRA) described in Section 408(a) or 408(b) of the Internal Revenue Code.
Signature of plan administrator or financial institution representative Printed name of plan administrator or financial institution representative Address (number and street) Date (month, day, year) Name of plan or financial institution


City Home telephone number State Other telephone number ZIP code

( )
Amount of investment

(

)

$
Method of payment (select one)

Direct rollover (check enclosed) Electronic funds transfer (EFT) PERF will provide bank and account names, routing code, and account number.

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INSTRUCTIONS FOR COMPLETING STATE FORM 51003, ROLLOVER ACCOUNT APPLICATION IMPORTANT: 1. Remove the form. Do not return these instructions to PERF. 2. Please type or print. Use black ink. 3. Complete all information. Remember to put your name and Social Security Number at the top of every page. 4. Return the completed form directly to PERF at the address below. General Information IC 5-10.2-3-10 permits active PERF members to deposit with PERF funds rolled over from any of the following sources: 1. A qualified plan described in Section 401(a) or 403(a) of the Internal Revenue Code. 2. An annuity contract or account described in Section 403(b) of the Internal Revenue Code. 3. An eligible plan maintained by a state, political subdivision of a state, or an agency or instrumentality of a state or political subdivision of a state under Section 457(b) of the Internal Revenue Code. 4. An individual retirement account (IRA) described in Section 408(a) or 408(b) of the Internal Revenue Code. The funds in your rollover account may be invested in any of the current investment options except the Guaranteed Fund. These funds may be withdrawn at any time prior to retirement. At retirement, these funds may be combined with your pension and your annuity savings account as part of your total benefit. STEP 1: Member Information Member's Social Security Number: Enter all nine digits of the Social Security Number. Your application will not be processed without this information. Date: Enter the date you completed the application. Member's First Name: Enter the first name. Member's Middle Initial: Enter the middle initial. Member's Last Name: Enter the last name. Member's Address: Enter the full street address, including apartment number or post office box number. City: Enter the city. State: Enter the state. ZIP Code: Enter the five or nine-digit ZIP code. Member's Telephone Number: Enter the telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail address: Enter the E-mail address, if available. STEP 2: Rollover Account Investment Directions The choices you make here will tell us how to invest your funds. Please select your investment choices. Important - Your investment choices must total 100%. Signature of Member: After making your choices, you must sign and date this section. IMPORTANT: The statute which created the rollover account investment option did not authorize investment of this money in the Guaranteed Fund. You cannot invest your rollover account in the Guaranteed Fund. STEP 3: Beneficiary Information Please check "Yes" or "No" for additional pages. Please provide the following information for each beneficiary: Beneficiary's Name: Enter your beneficiary's first, middle, and last names. Do not use initials. Beneficiary's Social Security Number: Enter all nine digits of the Social Security Number. Relationship to Member: Enter the relationship of your beneficiary to you; e.g. spouse, child, etc. Beneficiary's Address: Enter the full street address in which your beneficiary currently resides. City: Enter the city in which your beneficiary currently resides. State: Enter the state in which your beneficiary currently resides. ZIP Code: Enter the five or nine-digit ZIP code in which your beneficiary currently resides. Signature of Member: You must sign this page. STEP 4: Certification by Plan Administrator or Financial institution This section must be completed and signed or the rollover will not be accepted. Please have an authorized agent of the plan administrator or financial institution complete this section. Please indicate the type of plan by marking the appropriate box. Amount of Investment: The plan administrator or financial institution must enter the amount of the member's investment. Method of Payment: Select only one method of payment. Please do not staple checks to the application. Note: PERF will provide bank and account names, routing code, and account number for EFT transactions upon request.

Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the Public Employees' Retirement Fund at the following address: Public Employees' Retirement Fund 143 West Market Street Indianapolis, IN 46204 MEMBER NOTE ­ CHANGES TO INFORMATION If you have any changes to any of the information on this form, such as name or address, please notify PERF immediately at the address above. Notifying PERF will ensure that you receive correct and important information regarding your rollover account in the future.

HELPFUL INFORMATION PERF TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-888-526-1687 TDD (hearing impaired number) (317) 233-4160 PERF FAX Number (317) 234-5922 PERF on the Internet: www.in.gov/perf PERF MEMBER HANDBOOK (latest edition) PERF ANNUITY SAVINGS ACCOUNT INVESTMENT HANDBOOK Internal Revenue Service TELEPHONE NUMBERS: Toll-Free Number 1-800-829-1040 TDD (hearing impaired number) 1-800-829-4059 TeleTax 1-800-829-4477 IRS website: www.irs.gov E-MAIL: [email protected] IRS PUBLICATION 575, PENSION AND ANNUITY INFORMATION IRS PUBLICATION 590, INDIVIDUAL RETIREMENT ARRANGEMENTS Indiana Department of Revenue (DOR) TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4018 TDD (hearing impaired number) (317) 233-4952 Individual Income Tax Questions (317) 232-2240 Outside of Indianapolis ­ See DOR website DOR FAX Number (317) 233-2329 DOR website: www.in.gov/dor