Free 48789.FH11 - Indiana

REQUEST TO PURCHASE OUT OF STATE SERVICE
State Form 48789 (R3 / 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.

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.

PART 1 - APPLICANT INFORMATION & AUTHORIZATION TO RELEASE INFORMATION
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

(

)

(

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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

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)

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REQUEST TO PURCHASE OUT OF STATE SERVICE (continued)
State Form 48789 (R3 / 11-08) Approved by State Board of Accounts, 2008 Name of applicant (first, middle initial, last) Social Security Number *

PART 3 - PRIOR EMPLOYER INFORMATION & CERTIFICATION
Name of employee (first, middle initial, last) Social Security Number * Date of birth (month, day, year)

Name of employer

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

TITLE OF POSITION

(month, day, year)

START DATE

(month, day, year)

END DATE

STATUS MONTHS WORKED IF PART TIME, IN YEAR Full Time Part Time HOURS PER YEAR

Were any of these positions covered by a public employee or government sponsored retirement plan? If yes, Part 4 must be completed by the plan.

Yes

No

I hereby certify to the Indiana Public Employees Retirement Fund that, according to the official records available to me, the above named individual was employed as shown.
Signature of authorized agent Date (month, day, year)

Printed name of authorized agent

Telephone number

(

)

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REQUEST TO PURCHASE OUT OF STATE SERVICE (continued)
State Form 48789 (R3 / 11-08) Approved by State Board of Accounts, 2008 Name of applicant (first, middle initial, last) Social Security Number *

PART 4 - PUBLIC EMPLOYEES RETIREMENT SYSTEM CERTIFICATION
Amount of service with your system If this person has taken a distribution, please indicate the service balance prior to the distribution or withdrawal. Was any of this service purchased / transferred / carried over from another system? Years Months

Yes
System

No
Years Months

Is this person entitled to a retirement from your system based on the above service?

Has this person taken a distribution from your system?

Yes
Name of retirement fund or plan

No

Yes

No

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

Signature of authorized agent

Date (month, day, year)

Printed name of authorized agent

Telephone number

(

)

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INSTRUCTIONS FOR COMPLETING STATE FORM 48789, REQUEST TO PURCHASE OUT OF STATE SERVICE
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 Codes IC 5-10.3-7-4.5 and IC 5-10.3-7-9.5 provide for the purchase of out-of-state service credit with the Public Employees Retirement Fund (PERF). In order to qualify for the purchase of this credit, you must meet the following criteria: 1. You must be currently employed in a PERF-covered position. 2. You must have at least one (1) year of PERF or Teachers Retirement Fund (TRF) service. 3. Prior service in another state must be in a comparable position that would be creditable service with PERF if performed in Indiana. 4. You are no longer eligible to use those years to claim a retirement benefit from any other retirement system or fund. 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 Please complete Part 1 of this form. Have your current employer complete Part 2 and your prior employer complete Part 3. If any of your service with a prior employer was covered by a public employee or government sponsored retirement plan, that plan must complete Part 4. When all parts are complete, please return the form to the address on the last page. 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. The funds used for the purchase may come from a rollover of a members interest in: A tax-qualified retirement plan of a former employer (including a Section 401(k) plan), A traditional individual retirement account (IRA), A Section 403(b) plan, or A Section 457(b) governmental deferred compensation plan. The rollover contributions may contain only tax-deferred contributions and earnings, and may not include any post-tax contributions. PERF may also accept trustee-to-trustee transfers from a Section 403(b) plan or a Section 457(b) governmental deferred compensation plan. Members may pay directly for the cost of a service purchase in a single lump sum, or through installment payments over a period of up to 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. 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 the 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. Important: You must sign and date this section. Your application will not be processed if you do not.

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PART 2: Current Employer Information After you have completed Part 1, ask your 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. PART 3: Prior Employer Information & Certification After your current employer has completed Part 2, send the application to your prior employer so they may complete Part 3. If additional space is needed to list all positions, extra sheets may be attached. Please make certain that your name and Social Security number are at the top of each extra sheet. If you wish to purchase service from more than one employer, you may copy this page and have a copy completed by each employer. PART 4: Public Employees Retirement Plan Certification If any of your service with a prior employer was covered by a public employee or government sponsored retirement plan: After your prior employer has completed Part 3, send the application to the retirement system or plan in which you participated so they may complete Part 4. 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: www.in.gov/perf 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: 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

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