Free Indiana State Teachers' Retirement Fund - Indiana

RETIRED MEMBER DATA CHANGE
State Form 44504 (R3 / 2-06) Approved by the State Board of Accounts, 2006

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Website: www.in.gov/trf

PRIVACY NOTICE
Your TRF number is required on this form. Without it our agency cannot process your request. To obtain your number, send us a written request including your Social Security number, date of birth, current address and signature. We will mail you the information.

PLEASE USE BLACK INK ONLY

MEMBER IDENTIFICATION
Full name of member Home telephone number ( ) TRF number (required) Work telephone number ( ) Email address Date of birth Marital status Married Gender Male Single Female

CHANGE OF ADDRESS
Old address (number and street) City State Zip code New address (number and street) City State Zip code

MEMBER ATTESTS THAT ALL CHANGES ARE TRUE TO THE BEST OF HIS / HER KNOWLEDGE
Member signature Date

NAME CHANGE AFFIDAVIT
Previous name (please print or type) New name (please print or type)

I, the undersigned, hereby affirm that there is no fraudulent intent in the decision to change my name. It is my wish that from this day forward, my retirement account at the Indiana State Teachers' Retirement Fund be maintained under the new name as listed above: In lieu of this affidavit, one of the following documents may be submitted: Member signature Date

A copy of your marriage certificate A copy of your divorce decree restoring your former name; or A copy of the court order whereby you have legally changed your name.

NOTARY PUBLIC CERTIFICATION (For name change only)
State of ____________________________ SS: County of __________________________ Before me the undersigned, A Notary Public for___________________________________ County, Officer's county of residence State of ______________________, personally appeared ___________________________________________ Name of person And they, being first duly sworn by me upon their oath, says that the facts alleged in the foregoing instrument are true. Signed and sealed this ______ day of ________________________, 200__. (Signature) _______________________________________ _______________________________________ Printed or typed name of officer My commission expires:_____________________ (SEAL)