Free 50941.FH11 - Indiana

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State Form 50941 (R / 11-08) Approved by State Board of Accounts, 2008

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.


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.

Social Security Number * Date of birth (month, day, year)

Name of applicant (first, middle initial, last)

Number of years to be purchased (Please refer to the table in the instructions for the maximum amount.)

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

Home telephone number

Other telephone number

E-mail address





I authorize the release of any and all information as requested by the Fund pertaining to my application to purchase additional service credit.
Signature of applicant Date (month, day, year)

PART 2 - CURRENT EMPLOYER INFORMATION NOTE: Base annual salary should be given exclusive of overtime, lump-sum bonuses, travel allowances, etc.
Name of employer Account number of employer

Title of position

Date of hire (month, day, year)

Annual salary

I certify that the above named individual is employed by us in a PERF-covered position.
Signature of authorized agent Date (month, day, year)

Printed name of authorized agent

Telephone number



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. General Information Indiana Code IC 5-10.2-3-1.2 permits an active member to purchase one (1) year of additional service credit with the Public Employees Retirement Fund (PERF) for each five (5) years of PERF or Teachers Retirement Fund (TRF) covered employment. To be eligible to purchase this credit, you must: 1. Be currently employed in a PERF-covered position. 2. Have at least ten (10) years of PERF or TRF covered employment. This service may not be used in claiming a retirement benefit until payment in full has been made and you have accumulated ten (10) years of service, not including any purchased service. Procedures for Purchase of Service If you meet these criteria, please complete Part 1 of this form. Have your current employer complete Part 2. When both parts are complete, please return the form to PERF at the address on the last page of these instructions. We will calculate the cost of the service and return a purchase agreement to you. If you wish to purchase the service, you must complete the agreement and return it to the address on the agreement together with your payment. Payment may be made in the form of a trustee-to-trustee transfer, rollover, lump sum, or in installments for a period not to exceed five (5) years. Any installment shall bear interest at the actuarial rate effective on the date of the first installment. Any payments are subject to applicable Internal Revenue code limits and PERF may adjust any payments in a manner necessary to comply with those limits. In addition, PERF may deny an application for the purchase of service credit if the purchase would exceed the limitations under Section 415 of the Internal Revenue Service code. Distributions If you purchase service and elect to withdraw from PERF prior to becoming eligible to receive a monthly benefit, the amount you have paid plus the accumulated interest will be distributed to you. PART 1: Applicant Information Applicants Social Security Number: Enter all nine digits of your Social Security Number. Your application will not be processed without this information. Applicants Date of Birth: Enter your date of birth as MM/DD/YYYY. Applicants Name: Enter your first name, middle initial, and last name. Applicants Address: Enter your full street address, including apartment number or post office box number, city, state, and ZIP code. Applicants Telephone Number: Enter your 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. Number of years to be purchased: Enter the number of years of service you wish to purchase, up to the maximum number of eligible years. You may use the following table to determine the maximum number of years you are eligible to purchase. If your years of service are: Less than At least 15 10 20 15 25 20 30 25 35 30 40 35 45 40 50 45 You are eligible to purchase: 2 3 4 5 6 7 8 9

For additional years of service, please contact PERF. Be sure to sign and date this section of the form.

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PART 2: Current Employer Information After you have completed Part 1, ask you employer to provide the information in Part 2. Title of Position: Please enter the title of the position occupied by the employee. If you have provided information to PERF on the coverage of this position, please use the position title previously provided to PERF. Date of Hire: Please provide the date this member was hired into this position. Annual Salary: Please enter the members base annual salary. Do not include any additional compensation such as travel or housing allowances, overtime, lump sum bonuses, or incentives such as fees or commissions.

Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the Public Employees Retirement Fund 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 or address, please immediately notify PERF at the address above.

HELPFUL INFORMATION Public Employees Retirement Fund TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-888-526-1687 TDD (hearing impaired number) (317) 233-4160 FAX Number (317) 234-5922 Toll-Free FAX Number (866) 591-9441 PERF on the Internet: PERF MEMBER HANDBOOK (latest edition) 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: 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:

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