Free 18521.pdf - Indiana


File Size: 186.4 kB
Pages: 2
Date: March 18, 2003
File Format: PDF
State: Indiana
Category: Government
Author: TRF
Word Count: 723 Words, 4,706 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/18521.pdf

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Application for Voluntary Withdrawal
State Form 18521 (R15/2-03) Form approved by State Board of Accounts, 2003 PRIVACY NOTICE Your Social Security Number is being requested pursuant to IRS Code ยง 3405. Disclosure is mandatory and this document cannot be processed without it. Indiana State Teachers' Retirement Fund 150 West Market Street, Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 (888) 286-3544 [Toll-Free] Internet: www.in.gov/trf

WITHDRAWING MEMBER Once completed, return to the Fund for processing, which should take 6 to 8 weeks.

MEMBER DATA
Social Security Number TRF Number

Social Security Number
Date of Birth (mm/dd/yyyy)

First Name

Middle Initial

Last Name

Home Address

Home Telephone Number

Business Telephone Number

City

State

Zip Code

DISTRIBUTION INFORMATION

I elect a complete distribution of my Annuity Savings Account as follows:
SELECT ONLY ONE (1) FROM EACH COLUMN

Taxable Portion
Direct Rollover Paid Directly to me (less withholding) Partial Rollover in the amount of $ ___________, balance (less withholding) paid to me.

Non-Taxable Portion
Direct Rollover Paid Directly to me Partial Rollover in the amount of $ ___________, balance paid to me.

COMPLETE ONLY IF YOU SELECT A ROLLOVER

Taxable Portion
Name of Eligible 401(a), 403(b), or governmental 457(b) Retirement Plan or Traditional IRA

Non-Taxable Portion
Name of Eligible Defined Contribution Plan or Traditional IRA (This must be the complete name of the Eligible Plan or Traditional IRA as reported by the trustee to the IRS).

OPTIONAL STATE OF INDIANA TAX WITHHOLDING
Indiana income tax withholding for Indiana citizens is optional on payments from the Fund. If payment of taxes is not made at this time, taxes owed by Indiana citizens will be collected at a later date. If you wish to make a tax payment at this time, the Indiana tax rate is 3.4%. Do you wish to have money withheld from the taxable portion of your Annuity Savings Account, which you elected to have paid directly to you, for Indiana income taxes? (check one) Yes No

(CONTINUED ON REVERSE SIDE)

MEMBER AFFIDAVIT
I hereby declare that I am a member of the Indiana State Teachers' Retirement Fund; I make the acknowledgements and certifications set forth in the "DISTRIBUTION INFORMATION" and "OPTIONAL STATE OF INDIANA TAX WITHHOLDING" sections; I have left service in the public school system of the State of Indiana; I further declare that I am not currently qualified both by age and service for retirement benefits from either this Fund or the Public Employees' Retirement Fund; I certify that I am not planning to return to teaching service in the State of Indiana public school system during the next academic school year; I further declare that if I have ten or more years of creditable service, I understand that I am forfeiting my right to receive retirement benefits by withdrawing from the Fund unless I subsequently comply with the requirements for restoration of my creditable service. Having been duly sworn on oath, I declare that: G I am the individual applying for withdrawal from the Indiana State Teachers' Retirement Fund; G I have personally prepared this application; AND G The information that I have supplied is true to the best of my knowledge and belief.
Signature of Applicant Printed Name of Applicant Date

NOTARY CERTIFICATION
STATE OF COUNTY OF __________________________

SEAL
__________________________ Subscribed and sworn to (or affirmed) before me on this, the ______________ day of _____________________, 20_______.
Signature of Notary Public Printed Name of Notary Public (REQUIRED BY INDIANA LAW)

Date subscribed and sworn

County of Notary's Residence

Date of Notary Commission Expiration

CERTIFICATION OF EMPLOYING OFFICIAL
If you taught in the public school system of Indiana within the last three years, you must forward this application to the last Indiana public school at which you worked. That organization will complete the application and forward it to the Fund. Employing Unit: If this application has been forwarded to you, please complete the application by filling in the boxes below. After completion, please forward the application to the Indiana State Teachers' Retirement Fund. Thank you for your cooperation. I hereby certify that _____________________________________, Social Security Number , left

the service of the school system on the _______ day of ________________________, _______. This person is no longer employed by us.
County Unit Number Employer School Unit Telephone

Person to contact

Signature Treasurer / Authorized Official

Date Signed

Office Use Only Date of payment______Int._____ Date of Audit_________Int._____