Free 07096.FH11 - Indiana

APPLICATION FOR RETIREMENT BENEFITS
JUDGES RETIREMENT SYSTEM
State Form 7096 (R / 10-08)

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JUDGES RETIREMENT SYSTEM 143 West Market Street Indianapolis, Indiana 46204-2899 Telephone: (317) 233-4146 Toll free: (888) 526-1687

* 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. If you have not previously furnished proof of age to the fund, you must submit such documentation along with this application. Documents showing the date of birth may be an original or photocopy of a birth certificate, a baptismal or confirmation certificate, or a court decree. Attach an English translation to any foreign document. 3. Please have this application notarized. 4. Return the completed form to the Judges Retirement System at the above address. 5. If you have any questions or would like additional information regarding your benefits, call PERF at (888) 526-1687 or e-mail to questions @perf.in.gov. MEMBER INFORMATION

Social Security Number * Name (first, middle, last) Address (number and street, city, state, and ZIP code) Name of county where employed

Date (month, day, year) Telephone number

(

)

Last day at work (month, day, year)

I elect to accept retirement benefits as of ________________________. I will have served ____________ years, ____________ months as a judge in the State of Indiana. Pursuant to IC 33-13-8-10, I certify that I am at least sixty-two (62) years of age and have at least eight (8) creditable years of service as a judge, or I meet the conditions of the Rule of 85, pursuant to IC 33-13-9.1-4, and have conformed to all requirements of the law for retirement benefits. I further certify that I am neither receiving nor entitled to receive any salary from the State of Indiana for services performed after the date of acceptance of benefits. Accordingly, I hereby apply for retirement benefits.
Signature of applicant Printed name of applicant Date of signature (month, day, year)

CERTIFICATION OF NOTARY PUBLIC STATE OF ______________________________________ COUNTY OF _______________________________ SS: SEAL

Subscribed and sworn to before me, a notary public, on this ____________ day of _____________________________________, 20________.
Signature of notary public County of residence Printed name of notary public Date commission expires (month, day, year)

BENEFICIARY INFORMATION (governed by statute)
Social Security Number of spouse * Name of spouse (first, middle, last) Date of birth of spouse (month, day, year)

EMPLOYER CERTIFICATION I hereby certify the following information for the above-named applicant.
Last day of pay status (month, day, year) Signature of authorized agent Printed name of authorized agent Title of authorized agent Did the employer-employee relationship extend beyond the last day in pay status?

Yes
Date (month, day, year)

No