Free 51004.pdf - Indiana

ROLLOVER ACCOUNT INVESTMENT DIRECTION
State Form 51004 (R / 8-08)

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* PRIVACY NOTICE All Social Security Numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory; this form will not be processed without the information

INSTRUCTIONS: 1. Please TYPE or PRINT. Use black ink. 2. Return the completed form directly to PERF. Do not return the instruction page.

MEMBER INFORMATION
Social Security Number * First name Address (number and street) Middle initial Last name


City Home telephone number State Other telephone number ZIP code

( )
E-mail address

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ROLLOVER ACCOUNT INVESTMENT DIRECTIONS ­ All investment choices in this box must total 100%.
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Money Market Fund Bond Fund S&P 500 Index Fund US Small Companies Stock Fund International Equity Index Fund

I revoke any previous investment directions for my rollover account and hereby direct the above investments, effective this date. I understand that these investment directions are for my rollover account only and will not affect the investment of my annuity savings account.
Signature of member Date (month, day, year)

INSTRUCTIONS FOR COMPLETING STATE FORM 51004, ROLLOVER ACCOUNT INVESTMENT DIRECTION 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 at the address below. General Information This form is only for use with a rollover account. It may not be used for your annuity savings account. You have the right to change your investment direction at any time while you maintain a balance in your rollover account. However, your change will not take effect until the first day of the next calendar quarter: January 1, April 1, July 1, or October 1. This form must be received at least thirty (30) days prior to the date it is to take effect. If you leave PERFcovered employment and leave your money with the fund, you still retain the right to direct the investment of you account. This form revokes and replaces all previous investment directions for your rollover account. In choosing your investment directions, please make sure the percentages total 100% or the form will be returned. Investments may only be made in increments of 10%. This form must be correctly completed and signed in order to take effect. STEP 1: Member Information Member's Social Security Number: Enter all nine digits of the Social Security Number. Your application will not be processed without this information. Member's First Name: Enter the first name. Member's Middle Initial: Enter the middle initial. Member's Last Name: Enter the last name. Member's Address: Enter the full street address, including apartment number or post office box number. City: Enter the city. State: Enter the state. ZIP Code: Enter the five or nine-digit ZIP code. Member's Telephone Number: Enter the 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. STEP 2: Rollover Account Investment Directions Mark the appropriate box for the appropriate percentage. Do not mark more than one box on any line. Your selections must total 100% or this form will be returned. IMPORTANT: The statute which created the rollover account investment option did not authorize investment of this money in the Guaranteed Fund. You cannot invest your rollover account in the Guaranteed Fund. STEP 3: Member Certification After you have completed selecting your investment directions, you must sign and date the form, then return it to PERF. 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 Fax: (317) 234-5922 If you have not received a confirmation notice within three (3) weeks of mailing this form, please call PERF toll free at 888526-1687. MEMBER NOTE ­ CHANGES TO INFORMATION If you have any changes to any of the information on this form, such as name or address, please notify PERF immediately at the address above. Notifying PERF will ensure that you receive correct and important information regarding your rollover account in the future.

HELPFUL INFORMATION PERF TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-888-526-1687 TDD (hearing impaired number) (317) 233-4160 PERF FAX Number (317) 234-5922 PERF on the Internet: www.in.gov/perf PERF MEMBER HANDBOOK (latest edition) PERF ANNUITY SAVINGS ACCOUNT INVESTMENT HANDBOOK 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 E-MAIL: [email protected] 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