Free 29211.FH11 - Indiana

REQUEST FOR ESTIMATE OF BENEFITS
State Form 29211 (R5 / 10-08)

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.

INSTRUCTIONS:

1. Please type or print. Use black ink. 2. Complete all information. 3. Return the completed form directly to PERF. Do not return the instruction pages.

STEP 1 - MEMBER INFORMATION
Social Security Number * Date of birth (month, day, year)

Name of member (first, middle initial, last)

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

Home telephone number

Other telephone number

E-mail address

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STEP 2 - RETIREMENT INFORMATION
Regular / early retirement benefits anticipated last day of work (month, day, year) Disability benefits Social Security disability onset date (month, day, year) Anticipated date for beginning benefits (month, 01, year)

STEP 3 - ANTICIPATED RETIREMENT BENEFICIARY INFORMATION
Social Security Number * Date of birth (month, day, year)

Name of beneficiary (first, middle initial, last)

Relationship to member

MEMBER ACKNOWLEDGEMENT
Signature of member Date (month, day, year)

Printed name of member

INSTRUCTIONS FOR COMPLETING STATE FORM 29211, REQUEST FOR ESTIMATE OF BENEFITS
IMPORTANT: 1. Remove the form. Do not return these instructions to PERF. 2. Please type or print. Use black ink. 3. Complete all information. 4. Return the completed form directly to PERF. Important Information We can provide only one (1) estimate of benefits within any twelve (12) month period. Because estimates are prepared based on current information, actual benefits received at the time of retirement may differ. Regular / Early Retirement Benefits We can only provide an estimate of benefits once you are within one (1) year of being eligible for retirement: Age fifty (50) with fifteen (15) years of service Age sixty (60) with fifteen (15) years of service Age sixty-five (65) with ten (10) years of service You are at least fifty-five (55) and your age and your years of service add up to eighty-five (85) (Rule of 85) Disability Benefits In order to receive PERF disability benefits, you must: Have at least five (5) years of creditable service with PERF before the termination of salary, employer provided income protection benefits, Workers Compensation benefits, or leave under the Family and Medical Leave Act (FMLA). Be determined by the Social Security Administration to be disabled. Be receiving salary, employer provided income protection benefits, Workers Compensation benefits, or leave under the Family and Medical Leave Act (FMLA) as of the onset date established by Social Security. You must provide PERF with a copy of your Social Security award letter. STEP 1: Member Information Members Social Security Number: Enter all nine digits of your Social Security Number. Your form will not be processed without this information. Your application will not be processed without this information. Members Date of Birth: Enter your date of birth as MM/DD/YYYY. If you have not previously furnished proof of your age to PERF, you must submit such documentation along with this form. If you select Option 30, 40, or 50, you are also required to furnish proof of age for your beneficiary. Documents showing the date of birth such as a certified photocopy of a birth certificate, a baptismal or confirmation certificate, or a court decree are acceptable. Attach an English language translation to any foreign language document. Members Name: Enter your first name, middle initial, and last name. Members Address: Enter your full street address, including apartment number or post office box number, if applicable, city, state, and ZIP code to which you would like your estimate sent. Members Telephone Number: Enter the telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail Address: Enter the E-mail address, if available. STEP 2: Retirement Information Please complete the line for retirement or disability benefits. Do not complete both. Regular / Early Retirement Benefits Anticipated last day of work: Enter your anticipated last day of work as MM/DD/YYYY. Disability Benefits Social Security Onset date: Enter the onset date for your disability assigned by the Social Security Administration as MM/DD/YYYY. If you have not already provided PERF with a copy of your Social Security disability award letter, you will need to include a copy with this form. Anticipated beginning date of retirement benefits: Enter the beginning date of your retirement as MM/01/YYYY. This date cannot be earlier than the first day of the month after your last in a pay status with your employer, or the first day of the month after the disability onset date assigned by the Social security Administration. For example, if your last day in a pay status with your employer is January first, the earliest benefits can begin is February first. If your last day in pay status with your employer is January thirty-first, the earliest benefits can begin is February first. Also, if your last day in a pay status with your employer was more than six (6) months ago, then this effective date cannot be prior to six (6) months before PERF receives your completed retirement application.

STEP 3: Anticipated Retirement Beneficiary Information Please provide the following information for anyone you anticipate naming as beneficiary for one of the joint and survivor options (Options 30, 40, or 50) at retirement. If you do not provide this information, no estimate will be prepared for the joint and survivor options. Beneficiarys Social Security Number: Enter all nine digits of your beneficiarys Social Security Number. Beneficiarys Date of Birth: Enter your beneficiarys date of birth as MM/DD/YYYY. Beneficiarys Name: Enter your beneficiarys first name, middle initial, and last name. Relationship to Employee: Enter the relationship of your beneficiary to you; e.g. spouse, child, etc. Member Acknowledgement Please sign, print your name, and date the form.

Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the Public Employees Retirement Fund (PERF) at the following address: Public Employees Retirement Fund 143 West Market Street Indianapolis, IN 46204

MEMBER NOTE CHANGES TO INFORMATION If you have any changes to any of the information on this form, such as name, address, beneficiary information, etc., please immediately notify PERF at the address above so your estimate can be updated.

HELPFUL INFORMATION PERF TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-888-526-1687 TDD (hearing impaired number) (317) 233-4160 FAX Number (317) 232-1614 PERF on the Internet: www.in.gov/perf PERF MEMBER HANDBOOK (latest edition) PERF ANNUITY SAVINGS ACCOUNT INVESTMENT HANDBOOK Internal Revenue Service TELEPHONE NUMBERS: Toll-Free Number 1-800-829-1040 TDD (hearing impaired number) 1-800-829-4059 TeleTax 1-800-829-4477 IRS website: www.irs.gov IRS PUBLICATION 575, PENSION AND ANNUITY INFORMATION IRS PUBLICATION 590, INDIVIDUAL RETIREMENT ARRANGEMENTS Indiana Department of Revenue (DOR) TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4018 TDD (hearing impaired number) (317) 233-4952 Individual Income Tax Questions (317) 232-2240 Outside of Indianapolis See DOR website DOR FAX Number (317) 233-2329 DOR website: www.in.gov/dor