Free 44511.pdf - Indiana

APPLICATION FOR SURVIVING SPOUSE BENEFIT
State Form 44511 (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.in.gov/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. PART I ­ SURVIVING SPOUSE CERTIFICATION I hereby certify that I am the surviving spouse of:
Member's Name Member's Social Security Number

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.

Member's TRF Number

who died on

Date of Death

, 20 ______

and that we were united in marriage on

Date of Marriage

, __________

and that I elect to receive the eligible Surviving Spouse benefit as directed below: ALTERNATIVE I ALTERNATIVE II I hereby elect to have the Annuity Savings Account of my deceased spouse 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 my deceased spouse. I hereby elect a distribution to me equal to the "Federal Tax Basis" (after tax contributions) in the Annuity Savings Account of my deceased spouse as it existed on December 31, 1986, and receive the balance of the account as an annuity.
Address (Street Name or P.O. Box)

ALTERNATIVE III

Social Security Number of Surviving Spouse

Printed Name of Surviving Spouse

City

State

ZIP Code

Signature of Surviving Spouse

Telephone Number

(

)

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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)