Free 44510.pdf - Indiana

APPLICATION FOR SURVIVING SPOUSE PENSION BENEFIT
State Form 44510 (R3 / 11-06) Approved by the 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

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

PRIVACY NOTICE 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

Date of death (month, day, year)

Date of marriage (month, day, year)

who died on

and that we were united in marriage on

Pursuant to my status, I hereby make application to receive the surviving spouse pension benefit due to me as provided by Indiana Code, section 5-10.2-4-7. Any balance remaining in the member's annuity savings account is to be distributed to the designated beneficiary (ies).
Social Security number of surviving spouse Printed name of surviving spouse Address (number and street or P.O. box) City State ZIP code

Signature of surviving spouse

Telephone

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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)_________________________________ My commission expires:_____________________ __________________________________ Printed or typed name of officer

(SEAL)