Free 51145.FH11 - Indiana

APPLICATION FOR PARTICIPATION IN THE DEFERRED RETIREMENT OPTION PLAN (DROP)
1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND
State Form 51145 (R2 / 10-08)

1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND 143 West Market Street Indianapolis, Indiana 46204-2899

Reset Form

* This agency is requesting disclosure of Social Security Numbers in accordance with Internal Revenue Code; disclosure is mandatory and this form will not be processed without it.

INSTRUCTIONS:

1. Please type or print. Use black ink. 2. Complete all information. Remember to put your name and Social Security Number at the top of every page. 3. Return the completed form directly to the 1977 Fund. Do not return the instruction pages.

STEP 1 - MEMBER INFORMATION
Social Security Number * Date (month, day, year)

Name of member (first, middle initial, last)

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

Home telephone number

Other telephone number

E-mail address

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STEP 2 - DROP ELECTION DATES
DROP entry date (month, day, year) You must have twenty (20) years of service and be age fifty-two (52) by this date. This date cannot be earlier than when your DROP election form is mailed. DROP retirement date / effective date of retirement (month, day, year) This must be at least twelve (12) months after your DROP entry date, but cannot be more than thirty-six (36) months after this date .

MEMBER ACKNOWLEDGEMENT

I elect the above dates for participation in the Deferred Retirement Option Plan (DROP). I understand that in order to remain eligible for DROP benefits upon retirement, my choice for dates of entry and retirement under DROP cannot be changed after this form is received by the 1977 Fund. By signing below, I acknowledge that I have read and understand this statement.
Signature of member Date (month, day, year)

Printed name of member

1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND 143 West Market Street Indianapolis, Indiana 46204-2899

INSTRUCTIONS FOR COMPLETING STATE FORM 51145, APPLICATION FOR PARTICIPATION IN THE DEFERRED RETIREMENT OPTION PLAN (DROP) - 1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND IMPORTANT: 1. Remove the form. Do not return these instructions to the 1977 Fund. 2. Please type or print. Use black ink. 3. Complete all information. 4. Return the completed form directly to the 1977 Fund at the address below. STEP 1: Member Information Members Social Security Number: Enter all nine digits of your Social Security Number. Your application will not be processed without this information. Date of Application: Enter the date you completed the application. Members Name: Enter your first name, middle initial, and last name. Members Address: Enter your full street address, city, state, and the five or nine-digit ZIP code. Members Telephone Number: Enter your telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail Address: Enter the E-mail address, if available. STEP 2: DROP Election Dates DROP Entry Date: Please enter the date as MM/DD/YYYY. You must have at least twenty (20) years of service and be age fifty-two (52) by this date. This date cannot be earlier than the date your DROP election form is mailed to the 1977 Fund. DROP Retirement Date / Effective Date of Retirement: Please enter the date as MM/DD/YYYY. This must be at least twelve (12) months after your DROP entry date, but cannot be more than thirty-six (36) months after your DROP entry date . IMPORTANT: You may select any day of the month as a DROP entry date or a DROP retirement date. However, your DROP lump sum amount will be calculated based upon the number of completed calendar months. The length of the DROP period must be no less than twelve (12) months and no more than thirty-six (36) months. Your DROP retirement date is the first day your retirement benefit is effective. Your retirement is effective on the first day after your last day of employment. Please choose this date carefully. In order to be eligible to choose DROP benefits, your employer must certify to the 1977 Fund that your last day of paid employment was the day before your DROP retirement date. Example 1: If you select a DROP entry date of March 20, 2007, and a DROP retirement date of March 20, 2009, your DROP lump sum will be calculated based on twenty-four (24) completed months. Your DROP retirement date is the day after your last day of employment. In order to be eligible to choose the DROP benefit, your employer must certify that your last day of employment is March 19, 2009. Your pension will begin as soon as administratively possible and you will be paid a prorated retirement benefit of March 2009, and a full months pension benefit in April 2009. Example 2: If you select a DROP entry date of March 20, 2007, and a DROP retirement date of March 1, 2009, your DROP lump sum will be calculated based on twenty-three (23) months of time in the DROP because you will have been in the DROP for only twentythree (23) full months. In order to be eligible to choose the DROP benefit, your employer must certify that your last day of employment is February 28, 2009. Your pension will begin as soon as administratively possible and you will be paid a full months pension benefit for March 2009. Member Acknowledgement Please read the notice that your choice of DROP entry date and DROP retirement date cannot be changed after this form is received by the 1977 Fund. Sign, print your name, and date the form to acknowledge that you have read and understand the notice. Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the 1977 Fund at the following address: 1977 Police Officers & Firefighters Pension & Disability Fund 143 West Market Street Indianapolis, IN 46204 The 1977 Fund must receive this application prior to the DROP entry date. MEMBER NOTE CHANGES TO INFORMATION If you have any changes to any of the information on this form, such as name or address, please notify the 1977 Fund immediately at the address above. Notifying the Plan will ensure that you receive correct and important information regarding your benefits and taxes.

HELPFUL INFORMATION PERF TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-888-526-1687 TDD (hearing impaired number) (317) 233-4160 PERF FAX Number (317) 232-1614 PERF on the Internet: www.in.gov/perf 1977 Police Officers & Firefighters Pension & Disability Fund TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4146 The 1977 Fund may also be reached through the PERF toll-free number - just ask the operator. FAX Number (317) 234-1529 1977 FUND MEMBER HANDBOOK (latest edition) Internal Revenue Service TELEPHONE NUMBERS: Toll-Free Number 1-800-829-1040 TDD (hearing impaired number) 1-800-829-4059 TeleTax 1-800-829-4477 IRS website: www.irs.gov IRS PUBLICATION 575, PENSION AND ANNUITY INFORMATION IRS PUBLICATION 590, INDIVIDUAL RETIREMENT ARRANGEMENTS Indiana Department of Revenue (DOR) TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4018 TDD (hearing impaired number) (317) 233-4952 Individual Income Tax Questions (317) 232-2240 Outside of Indianapolis See DOR website DOR FAX Number (317) 233-2329 DOR website: www.in.gov/dor