Free 23226.pdf - Indiana

Reset Form

APPLICATION FOR RETIREMENT BENEFITS, PART I
State Form 23226 (R20 / 5-09) Approved by State Board of Accounts, 2009

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / Toll-free (888) 286-3544 Fax: (317) 232-3882 / E-mail: [email protected] Web site: www.in.gov/trf

PRIVACY NOTICE
Your Social Security number is being requested by this agency pursuant to the requirements of IRS Code 3405. This disclosure is mandatory and this form cannot be processed without this information

INSTRUCTION: All pages of this application must be submitted.

MEMBER INFORMATION
Last name Social Security number Current street address Date of birth First name Telephone number ( ) City State ZIP Code E-mail address MI TRF number

If moving, future address & future telephone number

Anticipated move date

From what School Corporation/State Facility are you retiring?

What is your last day of service?

Date of delayed retirement (only complete if you are not age eligible on your last service day)

Are you applying for regular retirement (most common)? You must be age 65 with 10 or more years of creditable service, age 60 with 15 or more years of creditable service, or between ages 55-59 if age and creditable service total a minimum of 85 (Rule of 85). Are you applying for early retirement? You must be between ages 50-59 with a minimum 15 years of creditable service but do not meet the Rule of 85. Is this a disability retirement? Available to members with 5 or more years of creditable service who become disabled as determined by the Social Security Administration while teaching in Indiana. Are you age 70 or older? If you are age 70 or older, you may elect to continue teaching while receiving retirement benefits. If you make this election, no ASA contributions may be made and no additional service credit or supplemental pension is earned. Your benefit will not increase even if you continue to work. Do you wish to make this election? If yes, what would you like to use as your retirement date? ___________________________ Have you ever been employed in a position covered by Public Employees' Retirement Fund (PERF)? If yes, please indicate the years and location of PERF Service. Dates employed___________________ Location (employer) _______________________________

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Individuals with service in both the Indiana State Teachers' Retirement Fund (TRF) and the Public Employees' Retirement Fund (PERF) have the choice of which fund from which to retire; however, you may choose only one. By submitting this application, you are choosing to retire from TRF. If you would like to retire from PERF, you may obtain an application at http://in.gov/perf.

ELECTION OF PENSION BENEFIT
Choose only one option below by placing an "X" in the appropriate box. Generally, your selection is irrevocable and cannot be changed after the first day of the month in which benefit payments are scheduled to begin.

A-1
5-Year Certain & Life (Regular Form of Retirement)

A-2
Straight Life

A-3
Modified Cash Refund Plus 5-Year Certain & Life

B-1
100% Survivor Benefit

B-2
66-2/3% Survivor Benefit

B-3
50% Survivor Benefit

Lifetime benefit to the member. In the event the member dies before receiving 5 years of payments, the beneficiary will receive the remainder of the 5 years of guaranteed payments. Members selecting this option should designate beneficiary selections below. Lifetime benefit to the member. Should you choose either the ASA 1 or ASA 7 option (see next page), the A-2 comes with a minimum amount provision that insures the member or beneficiary will receive a benefit at least equal to the Annuity Savings Account (ASA) balance at the time of retirement. For details about this minimum amount provision, see the General Directions. Members selecting this option should designate beneficiary selections below. Lifetime benefit to the member. In the event the member dies before receiving 5 years of payments, the beneficiary will receive the remainder of the 5 years of guaranteed pension payments. The Annuity Savings Account (ASA) is reduced with each monthly benefit paid; if the member dies before reducing this balance to $0.00, the beneficiary will receive a single payment of the amount remaining. This pension option is only available with the ASA 1 or ASA 7. Members selecting this option should designate beneficiary selections below. Lifetime benefit to the member. Guarantees upon the death of a member, the designated, qualified survivor will receive 100% of the member's monthly benefit for the remainder of the survivor's life. For an explanation of a qualified survivor, see the General Directions. Members selecting this option must designate a survivor below. Lifetime benefit to the member. Guarantees upon the death of a member, the designated, qualified survivor will receive 66-2/3% of the member's monthly benefit for the remainder of the survivor's life. For an explanation of a qualified survivor, see the General Directions. Members selecting this option must designate a survivor below. Lifetime benefit to the member. Guarantees upon the death of a member, the designated, qualified survivor will receive 50% of the member's monthly benefit for the remainder of the survivor's life. For an explanation of a qualified survivor see the General Directions. Members selecting this option must designate a survivor below.

For A-1, A-2, or A-3 only: Designate at least one primary beneficiary Social Security number Full name of beneficiary Date of birth Full name of beneficiary Full name of beneficiary For B-1, B-2, or B-3 only Full name of survivor
Social Security number Social Security number

Relationship Relationship Relationship

Primary Secondary Primary Secondary Primary Secondary

Date of birth Date of birth

Social Security number

Date of birth

Relationship

In addition to your pension selection, choose only one designation below by placing an "X" in the appropriate box. Members retiring between the ages of 50 and 62 may integrate TRF benefits with Social Social Security benefits. TRF pays a larger monthly benefit payment before age 62. However, Security benefit payments may be greatly reduced or terminated at age 62, depending on the Integration member's estimated monthly Social Security disbursement. As TRF does not work in conjunction with Social Security, this selection will NOT affect the amount of your benefit Yes No N/A received from Social Security. If you check yes, you must submit a copy of your most recent Social Security statement.

ELECTION OF ANNUITY SAVINGS ACCOUNT (ASA)
Choose only one option below by placing an "X" in the appropriate box. Generally, your selection is irrevocable and cannot be changed after the first day of the month in which benefit payments are scheduled to begin.

ASA 1

ASA 2 ASA 3 ASA 4

I elect to receive the total amount of my ASA paid as a monthly benefit. By choosing this alternative, I will combine the monthly pension with my ASA. This will allow me to receive a higher monthly benefit payment. A minimum amount provision insures an amount equal to the Annuity Savings Account (ASA) balance at the time of retirement will be paid either to the member or beneficiary. For more details about this minimum amount provision, see the General Directions. I elect to have the total amount of my ASA (less mandatory Federal Income Tax Withholding) paid directly to me. I elect to have ALL of the taxable portion of my ASA paid in the form of a Direct Rollover to an IRA or qualified Retirement Plan. I elect to receive a distribution paid directly to me of an amount equal to my tax basis (after-tax contribution) in my ASA balance as it existed on December 31, 1986. You must indicate your IRA or Qualified Plan information below. I elect to have PART of the taxable portion of my ASA paid in the form of a Direct Rollover to an IRA or a Qualified Retirement Plan. I elect to receive a distribution paid directly to me of an amount equal to my tax basis (after-tax contribution) in my ASA balance as it existed on December 31, 1986. Additionally, the part of the taxable portion of the distribution not directly rolled over (less mandatory Federal Income Tax Withholding) will be paid directly to me. You must indicate your IRA or Qualified Plan information below. Partial Rollover amount (Minimum $500)

$

.

ASA 5 ASA 6

ASA 7

I elect to defer distribution of my ASA until a later date. My account will continue to be invested with TRF under the same guidelines applicable to an ASA. I understand I may change the allocation strategy of my ASA quarterly. If you do not want your assets in this account paid to your estate at your death, you must designate a beneficiary below. I elect to receive a distribution of an amount equal to my tax basis (after-tax contribution) in my ASA balance as it existed on December 31, 1986 and defer distribution of the remainder of my ASA until a later date. My account will continue to be invested with TRF under the same guidelines applicable to an ASA. I understand changes to the allocation strategy of my ASA may be made quarterly. If you do not want your assets in this account paid to your estate at your death, you must designate a beneficiary below. I elect to receive a distribution of an amount equal to my tax basis (after-tax contribution) in my ASA balance as it existed on December 31, 1986. The remainder of my ASA will be paid as a monthly benefit. By choosing this option, I will combine the monthly pension with the remainder of my ASA so I may receive a higher monthly benefit payment. A minimum amount provision insures an amount equal to the Annuity Savings Account (ASA) balance at the time of retirement will be paid either to the member or beneficiary. For more details about this minimum amount provision, see the General Directions.

For ASA 3 or ASA 4 only

Individual Retirement Account or Qualified Retirement Plan account information
I acknowledge the designated plan is an IRA or Qualified Retirement Plan with provisions allowing it to accept direct rollovers on my behalf. TRF should make the direct rollover check payable to:
__________________________________________ as trustee of _______________________________________

Name of IRA company For ASA 5 or ASA 6 only: Designate at least one primary beneficiary Full name of beneficiary Social Security number Date of birth Full name of beneficiary Full name of beneficiary Social Security number Social Security number Date of birth Date of birth

Name of member

Relationship Relationship Relationship

Primary Secondary Primary Secondary Primary Secondary

ELECTION OF ROLLOVER SAVINGS ACCOUNT (RSA)
I have not created a Rollover Savings Account by rolling funds into TRF.
Choose only one option below by placing an "X" in the appropriate box. Generally, your selection is irrevocable and cannot be changed after the first day of the month in which benefits begin. A Rollover Savings Account (RSA) is created by rolling funds from an IRA, 457(b) Deferred Compensation Plan, a 403(b) Annuity, or another Qualified Retirement Plan into TRF.

RSA 1

RSA 2 RSA 3 RSA 4

I elect to receive the total of my RSA as a monthly benefit. I understand I will not receive any distribution from my RSA other than this monthly amount. By choosing this option, I will combine the monthly pension with my RSA to receive a higher monthly benefit payment. I elect to have the total amount of my RSA (less mandatory Federal Income Tax Withholding) paid directly to me. I elect to have my RSA paid in the form of a direct rollover to an IRA or a Qualified Retirement Plan. You must complete your IRA or Qualified Plan information below. I elect to have PART of my RSA paid in the form of a direct rollover to an IRA or Qualified Retirement Plan. Also, the part of the taxable portion of the distribution not directly rolled over (less mandatory Federal Income Tax Withholding) will be paid directly to me. You must complete your IRA or Qualified Plan information below. Partial Rollover Amount (Minimum $500) $ .

RSA 5

I elect to defer distribution of my RSA until a later date. My account will continue to be invested with TRF under the same guidelines applicable to a RSA. I understand I may change the allocation strategy of the RSA quarterly. Distribution must begin no later than the calendar year in which you reach age 70-½. If you do not want your assets in this account paid to your estate at your death, you must designate a beneficiary below.

For RSA 3 & RSA 4 only

Individual Retirement Account or Qualified Retirement Plan account information
I acknowledge the designated plan is an IRA or Qualified Retirement Plan with provisions allowing it to accept direct rollovers on my behalf. TRF should make the direct rollover check payable to:
__________________________________________ as trustee of _______________________________________

Name of IRA company For Rollover 5 only Full name of beneficiary Full name of beneficiary Full name of beneficiary Social Security number Social Security number Social Security number Date of birth Date of birth Date of birth

Name of member Relationship Relationship Relationship

Primary Secondary Primary Secondary Primary Secondary

** REEMPLOYMENT NOTICE **
If you reemploy in a TRF- or PERF-covered position before or within the minimum separation period of 30 days, you must notify TRF of your reemployment as your retirement will become void, your benefits will stop, and any benefits distributed must be repaid to TRF. Failure to timely notify TRF of your reemployment in a covered position within the minimum separation period could result in a large accrual of benefits that must be repaid to TRF. Also, for applications received after July 31, 2009, if you enter into a reemployment agreement prior to or at the same time you file your application for retirement in a position covered by TRF or PERF, you must notify TRF of your reemployment as your retirement will become void, your benefits will stop, and any benefits distributed must be repaid to TRF.

AFFIRMATION
I affirm that I am the above named applicant. I have carefully read (or in the case of disability, I have had read to me) and understand the application for retirement. All information is complete and true, represents my choices, and no material fact has been concealed or omitted therefrom. I understand that unless a statutory exception exists, my designations, options, and alternatives are irrevocable after the first day of the month my benefits are scheduled to begin. I also understand and have complied with the reemployment provisions as described above. I have had ample time to consider my choices and to seek counsel prior to making my selection(s) in making claim for a retirement benefit to be made payable to me pursuant to Indiana Code, section 5-10.2 and section 5-10.4. I acknowledge that the retirement benefit option selections I have made in this document are irrevocable except in the case of a survivor's death or some qualifying divorce decrees. Printed name of member Signature of member Date (mm/dd/yyyy)

NOTARY CERTIFICATION
State of _________________________________ SS: County of _______________________________ Before me the undersigned, a Notary Public for _________________________ County, State of _________________,
Officer's county of residence Name of person Officer's state of residence

personally appeared _______________________________________ and they, being first duly sworn by me upon their oath, say that the facts alleged in the foregoing instrument are true. Signed and sealed this _______ day of ______________________________, 20_______. ________________________________________________
Signature

________________________________________________
Name of officer (printed or typed)

My commission expires: _____________________ (SEAL)