Free 49614.pdf - Indiana

POWER OF ATTORNEY FOR ACTIVE MEMBERS
State Form 49614 (R / 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 Fax #: (317) 232-3882 Home page: www.in.gov/trf

INSTRUCTIONS: 1. 2. Please TYPE or PRINT. Please return to the Indiana State Teachers' Retirement Fund for verification and processing.

PRIVACY NOTICE Your TRF number is required on this form. Without it our agency cannot process your request. To obtain your number, send us a written request including your social security number, date of birth, current address, and signature. We will mail you the information.

MEMBER INFORMATION
First name Middle initial Last name

TRF number (required)

Date of birth (month, day, year)

Date (month, day, year)

Address (number and street or P.O. box)

Home phone number

( (
City State ZIP code

) )

Other phone number

ATTORNEY IN FACT POWERS Pursuant to Indiana Code, section 30-5-4-1, I, __________________________________________________, do hereby appoint

________________________________________ as my attorney in fact to sign my name and conduct business on my behalf in

relation to the following transactions involving the Indiana State Teachers' Retirement Fund: · Changing my mailing address · Changing my designated beneficiaries with regards to my annuity savings account · Changing my asset allocation directions with regards to the investment of my annuity savings account
Signature Printed name

NOTARY CERTIFICATE 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)