Free 50824.PDF - Indiana


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SOCIAL SECURITY CONSENT FORM
State Form 50824 (2-02) Approved by the State Board of Accounts 2002

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Toll Free: (888) 286-3544 www.in.gov/trf

CONSENT FOR DISCLOSURE OF INFORMATION TO INDIANA STATE TEACHERS' RETIREMENT FUND I, ____________________________________________, hereby authorize the Social Security Administration to release to the Indiana State Teachers' Retirement Fund (ISTRF) on an annual basis information documenting and/or confirming my eligibility or ineligibility to receive Social Security Disability Benefits. I do so with full knowledge that this information is confidential and as such protected from unauthorized disclosure by the Privacy Act, 5 U.S.C. 255a. It is also my understanding that any information provided shall be treated confidentially and be used solely to determine whether I am entitled to receive ongoing disability retirement benefit payments from ISTRF. Finally, I understand that this consent may be revoked at any time. Until such time as I do so revoke this consent in writing, however, this consent shall remain in full force and effect and the Social Security Administration may rely on this consent to responding to request from ISTRF each year, for as many years as ISTRF needs this information to confirm my continued eligibility to receive ISTRF benefits.

_______________________________________
Date

_______________________________________
Member's Name (printed)

___________________________________________ Member's ISTRF Number

___________________________________________ Member's Signature

____________________________________________ Member's Social Security Number

___________________________________________ ___________________________________________ Member's Address

To the Social Security Administration: This information is being requested to assist in the administration of disability retirement benefits for the above named individual. The information will be held to be confidential and shall not be disclosed other than in the administration of the retirement program except by written request or consent of the above named individual. _________________________________________
Date

_______________________________________
Signature of ISTRF Representative

Please forward the requested eligibility information to us at the above address. Thank you for assisting us in serving this individual.