Free 53663.FH11 - Indiana

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APPLICATION FOR SURVIVOR BENEFITS

STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN
State Form 53663 (R / 2-09)

STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN 143 West Market Street Indianapolis, Indiana 46204-2899 Toll Free: 1-888-526-1687

* This agency is requesting disclosure of Social Security Numbers in accordance with IRS Code 3405; disclosure is mandatory and this form will not be processed without it.

INSTRUCTIONS:

1. Please submit a copy of both the deceased members and the surviving spouses birth certificate. Documents showing the date of birth may be a photocopy of a birth certificate, a baptismal or confirmation certificate, or a court decree. Attach an English translation to any foreign document. 2. Please submit a copy of the members death certificate. 3. Please submit a copy of the marriage license. 4. Please have this application notarized. 5. All of the above items must be provided; this application will not be processed without them. DECEASED MEMBER INFORMATION

Name of deceased member (first, middle, last) - Please provide full name; do not use initials.

Social Security Number *

Address at time of death (number and street, city, state, and ZIP code)

Date of birth (month, day, year)

Date of death (month, day, year)

SURVIVING SPOUSE INFORMATION
Name of surviving spouse (first, middle, last) - Please provide full name; do not use initials. Social Security Number *

Permanent mailing address (number and street, city, state, and ZIP code)

Telephone number

Date of birth (month, day, year)

Date of marriage to deceased member (month, day, year)

(

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Date (month, day, year)

Signature of surviving spouse

CERTIFICATION OF NOTARY PUBLIC

STATE OF ___________________________________ SS: COUNTY OF _______________________________

The above information was subscribed and sworn to me this ____________ day of _______________________________, 20________.
Signature of notary public Printed name of notary public

County of residence

Date commission expires (month, day, year)