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APPLICATION FOR RETIREMENT BENEFITS, PART II
State Form 53486 (R2 / 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

INSTRUCTIONS
Please submit the following information within 30 days of the teacher's last day of service: · A description of your current retirement incentive program · Copy of the 2009-2010 contract · Complete the employer verification report on the following pages (retiring teachers will not receive their final benefit calculation until after this portion is received in our office) · Submit online at www.in.gov/trf, fax to (317) 233-0914, or send via US Mail to: Indiana State Teachers' Retirement Fund - 150 West Market Street, Suite 300 - Indianapolis, Indiana 46204

SECTION 1 (MEMBER PORTION)
Member's name Social Security number TRF number

SECTION 2 (EMPLOYER VERIFICATION)
School Year Contract Salary Salary Paid
(P31 Report)

Additional/Lost Earnings
(show + or -)

Additional/Lost Earnings Specific Reason
(Stipend is too general)

Summer School Contract Dates (mm/dd/yy)
From From From From From From From From From From From From From From From From To To To To To To To To To To To To To To To To

Summer School Contract Amount $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

2002-03

$

$

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

2003-04

$

$

2004-05

$

$

2005-06

$

$

2006-07

$

$

2007-08

$

$

2008-09

$

$

2009-10

$

$

APPLICATION FOR RETIREMENT BENEFITS, PART II (continued) Are there contract amounts higher than the years indicated above? If so, please provide the information below: Summer Salary Additional/Lost Additional/Lost Summer School School School Contract Earnings Paid Earnings Contract Contract Dates Year Salary Specific Reason (P31 Report) (show + or -) Amount (Stipend is too general) (mm/dd/yy) $ $ $ $ $ $
From From From From To To To To

$ $ $ $

$

$

Does the 2002-03 P31 Report on the previous page include any amount actually earned prior to July 1, 2002, but paid July 2002, or later from regular contract, summer school or other? Yes No Regular Contract $______________ Summer School/Other $_______________ Does the 2009-10 P31 Report on the previous page include any amount actually earned prior to July 1, 2009, but paid July 2009, or later from regular contract, summer school or other? Yes No Regular Contract $______________ Summer School/Other $_______________ Is the employee in the "96 Plan"? Yes No Salary Paid (P31 Report) $ $ $ $ Does the employer pay the employee contributions? Yes No Date the school began paying employee contributions:

Quarter 2009-10 1st Qtr. 2 Qtr. 3 Qtr. 4 Qtr.
st th rd nd

Contributions Paid by Employee $ $ $ $ $ $ $ $ $ $

Contributions Paid by Employer

Voluntary Post-Tax Contributions $ $ $ $ $

Voluntary Pre-Tax Contributions $ $ $ $ $

Days Worked

1 Qtr. $ 2010-11 Member's full name Member's last day of service Employer telephone number ( ) Employer address

Member's Social Security number Name of school corporation Employer fax number ( ) -

Member's TRF number TRF employing unit number

Employer e-mail address

I certify that the person whose name appears on this application as "member" has terminated employment and has not entered into any reemployment agreement with the employer listed on this application in violation of IC 5-10.2-4-8(f).

I hereby affirm under the penalty of perjury, according to official records, the above information is true and accurate. Employer contact name (printed) Employer contact signature Date signed (mm/dd/yyyy)