Free 53674.FH11 - Indiana

TRANSFER UNDER THE INDIANA UNIFORM TRANSFERS TO MINORS ACT
State Form 53674 (8-08)

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* This agency is requesting disclosure of Social Security Numbers in accordance with IC 4-1-8-1; disclosure is mandatory and this form cannot be processed without it.

To:
Name

Address (number and street, city, state, and ZIP code)

Regarding:
Name of minor Social Security Number *

The Indiana Public Employees Retirement Fund (PERF) hereby transfers to ________________________________________________, as
Name of custodian

custodian for ___________________________________________ under the Indiana Uniform Transfers to Minors Act (IC 30-2-8.5), the Name of minor following: The assets from this survivor benefit payment shall be held for the benefit of the above-named minor, who is the legal beneficiary of this payment from the 1977 Fund.
Signature of PERF Chief Operations Officer Date (month, day, year)

Signature of Deputy Director

Date (month, day, year)

By signing below, I acknowledge receipt of the property described above as custodian for the above-named minor under the Indiana Uniform Transfers to Minors Act and I agree to hold said proceeds for the exclusive benefit of the above-named minor. In consideration of the monthly benefit payment to me on behalf of the above-named minor, I, on behalf of myself, my estate, heirs, successors, and assigns, hereby release PERF from any and all claims, demands, causes of action, or suits that may exist or might be asserted in connection with said payment.
Signature of custodian Date (month, day, year)

CERTIFICATION OF NOTARY PUBLIC

STATE OF ___________________________________ SS: COUNTY OF _______________________________

The above information was subscribed and sworn to me this ____________ day of _______________________________, 20________.
Signature of notary public Printed name of notary public

County of residence

Date commission expires (month, day, year)