Free 44512.pdf - Indiana

APPLICATION FOR SURVIVING DEPENDENT BENEFIT
State Form 44512 (R3 / 10-06) Approved by State Board of Accounts, 2006

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Home Page: http://www.state.in.us/trf

PRIVACY NOTICE

INSTRUCTIONS: 1. 2. Please complete the necessary information by printing or typing in ink. Please sign the application in the presence of a Notary Public.

Your Social Security number is being requested by the Fund pursuant to Internal Revenue Service Code 3405. Disclosure of this information is mandatory. This form cannot be processed without it.

PART I ­ CERTIFICATION BY SURVIVING DEPENDENT OR COURT-APPOINTED GUARDIAN OF MINOR DEPENDENT I hereby certify that I am the court appointed guardian of: (Name Of Dependent) _________________________ a minor surviving child of (Name of Member) ______________________ (Member's Social Security Number) __________________________, (Member's TRF Number) __________________ who died on (Date of Death) ______________________, 20 _______. Pursuant to my status, I elect to have the eligible benefit received as directed below: (Check only one box) ALTERNATIVE I ALTERNATIVE II ALTERNATIVE III
Social Security Number of Dependent Printed Name of Dependent Signature of Guardian or Adult Dependent

I hereby elect to have the Annuity Savings Account of the deceased member paid to me as an annuity. I hereby elect a distribution to me equal to the entire amount credited to the Annuity Savings Account of the deceased member. I hereby elect a distribution to me equal to the "Federal Tax Basis" (after tax contributions) in the Annuity Savings Account of the deceased member as it existed on December 31, 1986, and receive the balance of the account as an annuity.
Address of Dependent (Street Name or P.O. Box) City Telephone State ZIP Code

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PART II ­ NOTARY PUBLIC CERTIFICATION State of ____________________________ SS: County of __________________________ Before me the undersigned, a Notary Public for___________________________________ County, Officer's county of residence State of ______________________, personally appeared ___________________________________________ Name of person And they, being first duly sworn by me upon their oath, says that the facts alleged in the foregoing instrument are true. Signed and sealed this ______ day of ________________________, 200__. (Signature) ___________________________________ ___________________________________ Printed or typed name of officer My commission expires:_____________________ (SEAL)