Free PART 1 - Indiana

Verification of Indiana Accredited Private School Teaching Service
State Form 49047 (R2/3-04) Approved by the State Board of Accounts 2004

Indiana State Teachers' Retirement Fund 150 West Market Street, STE 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Home Page: http://www.state.in.us/trf/ PRIVACY NOTICE

INSTRUCTIONS: Teacher: Please complete Part 1, then forward to Employing Indiana Accredited Private School Unit.

Employer: Please complete Part 2, then forward the form to the Indiana State Teachers' Retirement Fund.

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.

PART 1: TO BE COMPLETED BY THE TEACHER
Name of Teacher (First, Middle, Last) TRF Number (required)

Full Address (Street, City, State, ZIP Code)

Maiden/Other name used while teaching

Area Code and Telephone Number

I hereby certify that the service for which I am applying is service in an Indiana Accredited Private School. This service does not qualify for retirement credit in any public retirement system.
Signature Date

PART 2: TO BE COMPLETED BY THE ACCREDITED PRIVATE SCHOOL EMPLOYING UNIT The above teacher is seeking to verify teaching service from your Indiana accredited private school for the purpose of establishing retirement credit in this fund. Your cooperation will be appreciated. Name of Indiana Accredited Private School
School Full Address (Street, City, State, ZIP Code)

SCHOOL YEAR TAUGHT JULY 1 THROUGH JUNE 30

NUMBER OF DAYS TAUGHT

I hereby certify that this employing unit is an Indiana Accredited Private School. I certify that the above individual performed the indicated service as an educational administrator or classroom teacher.
Signature of Employing Official Date Signed (Month, Day, Year)

Printed Name of Employing Official

Title

Area Code and Telephone Number