Free 53971.FH11 - Indiana

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State Form 53971 (6-09) Approved by State Board of Accounts, 2009

1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND 143 West Market Street Indianapolis, Indiana 46204-2899 Telephone: (317) 233-4162 Toll-free: (888) 526-1687 Local fax: (317) 234-5922 Toll-free fax: (866) 591-9441

* 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.

Indiana Code 36-8-8-8.3 permits members to purchase service credit for up to two (2) years of prior military service. This service may not be used in claiming a retirement or disability benefit until payment in full has been made and you have accumulated ten (10) years of service, not including any purchased military or out-of-state service. QUALIFICATIONS In order to purchase this credit you must meet the following criteria: 1. You must be currently employed in a 1977 Fund covered position and have at least one (1) year of service credit. 2. You must have served on active duty in the armed services of the United States for at least six (6) months (only two (2) years of service may be purchased). 3. You must have received an honorable discharge from the armed services. 4. You must be able to provide a DD Form 214, Certificate of Release or Discharge from Active Duty, for each period of service you want to purchase. These forms may be requested from the National Archives at The armed services of the United States include the United States Army, Navy, Air Force, Marine Corps, and Coast Guard. PROCEDURES FOR PURCHASE OF SERVICE If you meet these criteria, complete Parts 1 and 2 of this form. Your current employer must complete Part 3. When all parts are complete, forward the form to PERF at the above address. Be sure to include copies of all DD Form 214s covering the service you want to purchase. The Fund will calculate the cost of the service and return a purchase agreement to you. If you want to purchase the service, you must complete the agreement and return it to the appropriate retirement fund with your payment. Payment may be made in a 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 Service (IRS) limits and the Fund may adjust any payments in a manner necessary to comply with those limits. In addition, the Fund may deny any application for the purchase of military credit if the purchase would exceed the limitations under Section 415 of the IRS Code. DISTRIBUTIONS If you purchase service and elect to withdraw from the Fund prior to becoming vested (ten (10) years of service), the amount you have paid plus accumulated interest will be distributed to you. PART 1 - MEMBER INFORMATION & AUTHORIZATION
Social Security Number * Name of applicant (first, middle initial, last) Address (number and street, city, state, and ZIP code) Home telephone number Other telephone number E-mail address Date of birth (month, day, year)




Date (month, day, year)

I authorize the release of any and all information as requested by the Fund pertaining to my request to purchase prior military service credit with the Fund.
Signature of applicant

PART 2 - SERVICE HISTORY Branch of Service Service Start Date
(month, day, year)

Service End Date
(month, day, year)


Total Service

PART 3 - CURRENT EMPLOYER INFORMATION NOTE: Base annual salary should be given exclusive of overtime, lump-sum bonuses, travel allowances, etc.
Name of employer Title of position Account number of employer Date of hire (month, day, year) Telephone number of employer



Annual salary

I certify that the above named individual is employed by us in a 1977 Fund covered position.
Signature of authorized agent Printed name of authorized agent Date (month, day, year)