Free 52658.FH11 - Indiana

RESOLUTION AUTHORIZING AN AGENT TO ACCEPT PENSION LIABILITY ON BEHALF OF THE GOVERNING BODY
State Form 52658 (R / 4-09)

PUBLIC EMPLOYEES RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2801 Telephone: (317) 233-4162

Please read the attached instructions before completing this form.
Name of employer Account number

Reset Form

RESOLUTION RESOLVED, that ___________________________________________________________________________________________________________,
Name(s)

___________________________________________________________, of _________________________________________________________ be,
Title Political subdivision

and hereby is, fully authorized and empowered to act on behalf of and in the name of ______________________________________________________
Political subdivision

as its agent to accept pension liability, pursuant to IC 5-10.2-3-1 and further to execute and deliver documents related to the Public Employees Retirement Fund (PERF) of Indiana. This resolution will remain in full force and effect until modified or rescinded by subsequent resolution and receipt thereof in writing by the Director of PERF. Adopted this ________ day of ______________________________ , ____________.
Day Month Year

SIGNATURES OF GOVERNING BODY (BOARD MEMBERS)
Title of governing body

Signature

Signature

Signature

Signature

Signature

Signature

Signature

Signature

NOTE The Agent authorized must be named and not designated by job title, unless such position is an elected position, such as Clerk-Treasurer. This Resolution supersedes any other Resolution you have on file. Therefore, please include ALL agents past and current who will be authorized to accept pension liability. We require the original signatures of your Governing Body. Copies are not acceptable.

INSTRUCTIONS FOR STATE FORM 52658, RESOLUTION AUTHORIZING AN AGENT TO ACCEPT PENSION LIABILITY ON BEHALF OF THE GOVERNING BODY
1. Employer Name - Enter the complete name of the employer (Do not use initials).

2. Account Number - Enter the account number of the employer. (For Municipalities, this would be the 3 or 4 digit number assigned to you by the PERF office. If you are a State University, this would be an 8000 number).

3. Names - Name of the individual(s) designated to accept pension liability on behalf of the employers governing body.

4. Title - Enter the title of the individual(s) designated to accept pension liability on behalf of the employers governing body.

5. Political Subdivision - Enter the complete name of Political Subdivision (employer (entity) name).

6. Date of Adoption - Enter day, month and year Resolution was adopted by the Governing Body.

7. Title of Governing Body - Title of the Town, City or County Council, Library, Township, or School board or any fiscal body that governs the affairs of the political subdivision.

8. Signatures of the Governing Body - We require original signatures of your Governing Body. Copies and faxes are not acceptable. Two-thirds of the Governing Bodys signatures are required. The Agent authorized must be named and not designated by job title, unless such position is an elected position, such as Clerk-Treasurer. However, for our records please also include the name of the elected official. Once a Resolution for the elected position has been filed with the PERF office, it is not necessary to complete a new one when a change in the elected official occurs. Notification in writing from the newly elected official is all that is required to update PERFs records. This Resolution supersedes any other Resolution you have on file. Therefore, please include ALL agents past and current who will be authorized to accept pension liability.