Free 52006.pdf - Indiana

Indiana State Teachers' Retirement Fund
JOSEPH E. KERNAN, Governor WILLIAM E. CHRISTOPHER, Ph.D., Executive Director
150 West Market Street, Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 Toll-Free: (888) 286-3544 FAX: (317) 232-3882 TTD: (317) 233-3306 Home Page: http://www.in.gov/trf E-mail: [email protected]

REQUEST TO PURCHASE ADDITIONAL SERVICE CREDIT
PRIVACY NOTICE All Social Security Numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory and this form will not be processed with this information. General Information

Indiana Code 5-10.2.-3-1.2 permits an active member to purchase one (1) year of additional service credit with the Indiana State Teachers' Retirement Fund (ISTRF) for each five (5) years of ISTRF or Public Employees' Retirement Fund (PERF) covered employment. Eligibility to purchase Air Time Service: 1. Currently employed in a TRF covered position. 2. Have at least ten (10) years of TRF or PERF 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.

If your years of service are: At least 10 15 20 25 30 35 40
45

Less than 15 20 25 30 35 40 45
50 Procedures for Purchase of Service

You are Eligible to Purchase 2 3 4 5 6 7 8
9

If you meet these criteria, please complete Part 1 of this form. Have your current employer complete Part 2. When both parts are completed, please return the form to ISTRF. Upon receipt of the complete form we will calculate the cost of the service and return an assessment to you. If you wish to purchase the service, you must complete the assessment and return it the ISTRF along with your payment. Checks are to be made out to the: INDIANA STATE TEACHERS' RETIREMENT FUND. Refunds If you purchase service and elect to withdraw from TRF prior to becoming eligible to receive a monthly benefit, the amount you have paid plus accumulated interest will be refunded to you.

Request to Purchase Additional Service Credit
State Form 52006 (12-04) Approved by the State Board of Accounts, 2004

Indiana State Teachers' Retirement Fund 150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Telephone: (317) 232-3860

INSTRUCTIONS:

1. Please complete Part 1, then forward to employing school unit. 2. Please complete Part 2, then forward to the Indiana State Teachers' Retirement Fund.

Toll Free: (888) 286-3544 e-mail: [email protected] www.in.gov/trf PRIVACY NOTICE
Your Social Security Number is requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory; this form will not be processed without this information.

Part 1: Applicant Information and Authorization to Release Information I authorize the release of any and all information as requested by the Fund pertaining to my application to purchase additional service credit with the Fund. First name Social Security number Address (number and street) City Home telephone E-mail address Number of years I wish to purchase (Please refer to the table in the instructions for the maximum amount) Signature Date (mm/dd/yyyy) State Other telephone ZIP MI Last name Date of Birth (mm/dd/yyyy)

Part 2: Current Employer Information This certifies that the above named individual is employed by us in a TRF covered position. Hire Date (mm/dd/yyyy) Signature of authorized agent Printed name of authorized agent Name of employer Title of position Annual salary Date (mm/dd/yyyy) Telephone number School unit number

Note: Base annual salary should be given exclusive of overtime, lump-sum bonuses, travel allowances, etc.