Free 50928.FH11 - Indiana

APPLICATION TO START OR STOP PAYMENT OF RETIREMENT BENEFITS TO A REVOCABLE TRUST
State Form 50928 (R2 / 6-09)

PUBLIC EMPLOYEES RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2899

Reset Form

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

Indiana Code 5-10.2-4-7(d) allows a member to direct their monthly benefit payment to a Revocable Trust. In order to qualify, the trust must permit unrestricted / unconditional access to amounts held in the trust and must be revocable at any time. Members may make this election at the time they retire or at any time thereafter. To Start Payments If you wish to begin directing your benefit payments to an eligible Revocable Trust, you should complete the Member Information section on this page and Part A of this form. Part B may be discarded. Submit an Authorization for Deposit of Recurring Payment (State Form 39175) with this application. Direct deposit is the preferred method to disperse monthly benefit payments. IMPORTANT: You should consult with your tax advisor before completing this form. You may need to obtain a Taxpayer Identification Number other than your Social Security Number for the revocable trust. To Stop Payments If you wish to stop further payments to a Revocable Trust you should complete the Member Information section on this page and Part B of this form. Part A can be discarded. Please return the completed form to PERF at the above address.

MEMBER INFORMATION
Name of member (last, first, middle initial) Social Security Number *

Address (number and street, city, state, and ZIP code)

Home telephone number

Other telephone number

(

)

(

)

E-mail address

Page 1 of 3

APPLICATION TO START OR STOP PAYMENT OF RETIREMENT BENEFITS TO A REVOCABLE TRUST (continued)
State Form 50928 (R2 / 6-09) Name of member (last, first, middle initial) Social Security Number *

PART A: REVOCABLE TRUST AUTHORIZATION & AFFIDAVIT Complete this section only if you wish your monthly benefit paid to a revocable trust. I hereby certify that I have requested the Indiana Public Employees' Retirement Fund pay my monthly retirement benefit to my Revocable Trust identified as: __________________________________________________________________________________, ____________________________________________
Print name of trust Social Security Number* or taxpayer identification number

I further certify that the before stated trust complies with terms set forth in Indiana Code section 5-10.2-4-7(d). I can revoke the trust at any time and I have unconditional access to trust funds. I acknowledge and agree that the payee designation will be in my name Revocable Trust. I further acknowledge and agree that, should there be a change in the terms or conditions of the trust instrument that would conflict with the provisions of IC 5-10.2-4-7(d), I will immediately notify the Fund and cooperate with the Fund to ensure that retirement benefit distributions are made in compliance with law. I also hereby agree and acknowledge that the terms of this instrument shall be binding upon my heirs, executors, administrators and assigns and I will hold the Fund harmless for any and all damages suffered as a result of any misrepresentation made in this instrument or by any act or omission with regard to the terms or administration of the trust. I also hereby acknowledge that I understand the terms of this affidavit and any ambiguities herein are to be resolved in favor of the Indiana Public Employees' Retirement Fund. I hereby acknowledge that I have had ample time and opportunity to secure legal counsel for the purpose of explaining any of these declarations contained within. I affirm, under the penalties for perjury, that the foregoing representations are true.
Signature of member Date (month, day, year)

Printed name of member

STATE OF ______________________________________ COUNTY OF _______________________________

SS:

Subscribed and sworn to before me, a notary public, in and for the state and county above named, by the said member, _____________________________________________________________ on this ____________ day of _____________________________________, 20________.
Signature of notary public Printed name of notary public

SEAL

County of residence

State of residence

Date commission expires (month, day, year)

Page 2 of 3

APPLICATION TO START OR STOP PAYMENT OF RETIREMENT BENEFITS TO A REVOCABLE TRUST (continued)
State Form 50928 (R2 / 6-09) Name of member (last, first, middle initial) Social Security Number *

PART B: REVOCABLE TRUST STOP PAYMENT AFFIDAVIT Complete this section only if you wish to stop payment to a revocable trust. Effective with the receipt to this notice I hereby authorize and direct the Public Employees' Retirement Fund to stop payment of my monthly benefit to my Revocable Trust. I understand that it is my responsibility to submit this form in a timely fashion and that failure to do so will absolve the Fund from any responsibility for payments that may be misdirected.
Signature of member Date (month, day, year)

Printed name of member

STATE OF ______________________________________ COUNTY OF _______________________________

SS:

Subscribed and sworn to before me, a notary public, in and for the state and county above named, by the said member, _____________________________________________________________ on this ____________ day of _____________________________________, 20________.
Signature of notary public Printed name of notary public

SEAL

County of residence

State of residence

Date commission expires (month, day, year)

Page 3 of 3