Free 41625.pdf - Indiana

VERIFICATION OF PRIOR IN STATE TEACHING SERVICE
State Form 41625 (R6 / 12-06) Approved by State Board of Accounts, 2006

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

PRIVACY NOTICE

INSTRUCTIONS: Teacher: Employer: Please complete Part 1, then forward to Employing School Unit Please complete Part 2, then forward form to the Indiana State Teachers' Retirement Fund PART 1: TO BE COMPLETED BY THE TEACHER Name of Teacher (First, Middle, Last)

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.

TRF Account Number (required)

Full Address (Street, City, State, and ZIP code)

Maiden/Other name used while teaching

Area Code and Telephone Number

PART 2: TO BE COMPLETED BY THE EMPLOYING UNIT The above teacher is seeking to verify teaching service from your school district for the purpose of establishing retirement credit in this fund. Pursuant to Title 515 IAC 1, by signing below, you are verifying that the above teacher was qualified to serve as a teacher. Name of School School Full Address (Street, City, State, and ZIP code)

SCHOOL YEAR TAUGHT JULY 1 THROUGH JUNE 30

NUMBER OF DAYS TAUGHT

SALARY EARNED

POSITION

THE SERVICE CREDIT ABOVE WAS IN A PUBLIC SCHOOL COVERED UNDER THE INDIANA STATE TEACHERS' RETIREMENT FUND YES NO

PLEASE NOTE THAT IF ANY SERVICE OCCURRED AFTER JULY 1, 1995, THIS FORM WILL NOT BE CONSIDERED COMPLETE BY THE INDIANA STATE TEACHERS' RETIREMENT FUND UNLESS THE EMPLOYER HAS PAID ALL CONTRIBUTIONS IN ACCORDANCE WITH INDIANA CODE, SECTION 5-10.4-7. Signature of Employing Official Date Signed (Month, Day, Year)

Printed Name of Employing Official

Telephone Number

Fax Number