Free 53688.FH11 - Indiana

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APPLICATION FOR PARTICIPATION IN THE DEFERRED RETIREMENT OPTION PLAN (DROP)
STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN
State Form 53688 (R2 / 4-09)

STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN 143 West Market Street Indianapolis, Indiana 46204-2899

* 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. 3. Return the completed form directly to PERF. Do not return the instruction pages.

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

Name of deceased 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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)

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STEP 2 - DROP ELECTION DATES
DROP entry date (month, day, year) You must be eligible to receive an unreduced annual retirement allowance by this date. DROP retirement date / effective date of retirement (MM, 01, YYYY)

____ 01 ______
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 and must be on or before the mandatory retirement age.

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 State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan. By signing below, I acknowledge that I have read and understand this statement.
Signature of member Date (month, day, year)

Printed name of member

STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN 143 West Market Street Indianapolis, Indiana 46204-2899

INSTRUCTIONS FOR COMPLETING STATE FORM 53688, APPLICATION FOR PARTICIPATION IN THE DEFERRED RETIREMENT OPTION PLAN (DROP) - STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN
IMPORTANT: 1. Remove the form. Do not return these instructions to the State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan. 2. Please type or print. Use black ink. 3. Complete all information. 4. Return the completed form directly to the State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan at the address below. STEP 1: Member Information Members Social Security Number: Enter all nine digits of the 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 the first name, middle initial, and last name. Members Address: Enter the full street address, city, state, and the five or nine-digit ZIP code. Members Telephone Number: Enter the 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 be eligible to receive an unreduced annual retirement allowance by this date. This date cannot be earlier that the date your DROP election form is mailed to the State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan. DROP Retirement Date / Effective Date of Retirement: Please enter the date as MM/DD/YYYY. This date 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. This date can also be no later than the first day of the month following your sixty-fifth (65th) birthday. If you became a participant after turning fifty (50) years old, your effective date of retirement must be the earlier of: 1) the first day of the month following your sixty-fifth (65th) birthday, or 2) the first day of the month following your completion of fifteen (15) years of service. 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 of the month following your last day in pay status. Please choose this date carefully. In order to be eligible to choose DROP benefits, your employer must certify your last day of paid employment to the State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan. 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 State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan. Sign, print your name, and date the form to acknowledge that you have read and understand the notice; then return it to the Plan. Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan at the following address: State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan 143 West Market Street Indianapolis, IN 46204 The State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan 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 State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan 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) 234-5922 Toll-Free FAX Number (866) 591-9441 PERF on the Internet: www.in.gov/perf State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4146 The State Excise Police, Gaming Agent, Gaming Control Officer & Conservation Enforcement Officers Retirement Plan may also be reached through the PERF toll-free number - just ask the operator. FAX Number (317) 234-5922 Toll-Free FAX Number (866) 591-9441 STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN MEMBER HANDBOOK (latest edition) Internal Revenue Service TELEPHONE NUMBERS: Toll-Free Number 800-829-1040 TDD (hearing impaired number) 800-829-4059 TeleTax 800-829-4477 IRS website: www.irs.gov E-MAIL: [email protected] 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