Free 49530.pdf - Indiana

VERIFICATION OF OUT-OF-STATE TEACHING SERVICE
State Form 49530 (R4 / 12-06) Approved by State Board of Accounts, 2006

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 or 1-888-286-3544 Fax Number (317) 232-3882 Web Address: http://www.in.gov/trf

INSTRUCTIONS Member: Please complete Part 1 and forward to the out-of-state school system. Employer: Please complete part 2 and forward to your State's Teacher Retirement Fund.

PRIVACY NOTICE
Your TRF number is required on this form. Without it our agency cannot process your request. To obtain your number, send 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 MEMBER Name of Teacher (First, Middle, Last) Full Address (Street, City, State, and ZIP code) New Address Last Four Digits of SSN TRF Account Number (required) Maiden/Other name used while teaching Telephone Number

PART 2: TO BE COMPLETED BY THE EMPLOYING UNIT The above member is seeking to verify teaching service from your school district for the purpose of establishing retirement credit in this fund. By signing below, you are verifying that the above member was qualified to serve as a teacher in the public school system of your state, or post secondary teaching service performed at a public institution where the teaching service qualified or would qualify in your state's public retirement system. Name of School Corporation School Full Address (Street, City, State, and ZIP code)

SCHOOL YEAR TAUGHT JULY 1 THROUGH JUNE 30

NUMBER OF DAYS TAUGHT THAT SCHOOL YEAR

Signature of Employing Official

Date Signed (Month, Day, Year)

Printed Name of Employing Official

Telephone Number

Fax Number

VERIFICATION BY OUT-OF-STATE RETIREMENT SYSTEM
INSTRUCTIONS: Unless otherwise directed, please complete and return this form to the Indiana Teachers' Retirement Fund at the above address.

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 or 1-888-286-3544 Fax Number (317) 232-3882 Web Address: http://www.in.gov/trf

The person named on the reverse side of this form is an active member of the Indiana State Teachers' Retirement Fund. This person wishes to establish credit for their out-of-state service as reported on the reverse side. Indiana law, under certain conditions, does not permit the purchase of out-of-state service credit by members who are receiving a retirement benefit from another state or who have vested rights to a benefit to be paid at some time in the future. Therefore, to assist us in helping this member establish out-of-state service, would you please answer the questions below that indicate eligibility for retirement benefits from your system. Your assistance is greatly appreciated. Was the person a member of your state retirement system? Is the person receiving or entitled to receive a benefit from your State based on this service? Was this non-contributory service? If contributory service, has the member received a refund of contributions? If yes, please indicated the date of the refund and the number of years cancelled by refund: Date of refund ____________ Number of years cancelled by refund ___________ Yes No Yes Yes Yes Yes No No No No

If the person does not return to teaching in your state, will the person be eligible to receive a benefit from your system? Does this person have credit in your system for employment from another state? If so, please indicate the State(s) and year(s) below. Does your system have a restriction against using vested service in your system to qualify for a benefit in Indiana?

Yes

No

Yes

No

Please correct or complete the number of days taught if reported in error or left blank by the employing unit. (See reverse side of this form for details supplied by the employing unit.) Comments:
___________________________________________________________________________________________

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Signature of Official Name of Retirement System Address (Street, City, State, Zip)

Title

Area Code and Telephone Number:

Fax Number

Date (Month, Day, Year)