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APPLICATION FOR RETIREMENT BENEFITS
State Form 52696 (R2 / 2-09)

PROSECUTING ATTORNEYS RETIREMENT FUND

PROSECUTING ATTORNEYS RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2899 Toll Free: 1-888-526-1687

* 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. 2. Please submit a copy of both the members and the spouses birth certificate. Documents showing the date of birth may be a 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. Sign Step 5 in front of a notary public, then the notary public must sign, date, and seal it. 4. All of the above items must be provided; this application will not be processed without them. STEP 1 - MEMBER INFORMATION
Date of application / todays date (month, day, year) Date of birth (month, day, year)

Name of member (first, middle initial, last) Social Security Number * Address (number and street, city, state, and ZIP code) Home telephone number Other telephone number E-mail address

(

)

(

)
Date of retirement (month, 01, year)

STEP 2 - DATE OF RETIREMENT Effective date of retirement benefits: This date can be no earlier that the first day of the month following the last day in pay status, but not prior to six (6) months before the Public Employees Retirement Fund Board of Trustees receives your completed application. If your benefits will not begin the month following your termination from employment, please specify the future date. STEP 3 - SPOUSE INFORMATION
Marital status (check one) If married, name of spouse (last, first, middle initial) Date of birth of spouse (month, day, year)

Married

Single

Social Security Number of spouse *

STEP 4 - EMPLOYER CERTIFICATION OF LAST DAY IN PAY STATUS - To be completed by your employer. Federal law prohibits the Prosecuting Attorneys Retirement Fund (PARF) from making distributions from the Fund prior to separation from employment. Uninterrupted service in any capacity or reemployment that is a continuation of employment will prevent PARF from making distributions to the employee from the Fund. Last day in pay status is the last day for which this employee was entitled to receive his or her regular wages. It will typically not be the last check date. Regular wages paid may include pay for a day worked, a sick day, vacation day or another paid leave permitted under your personnel policy. The last day in pay status is needed to process this members benefit.
Last day in pay status (month, day, year) Did the employer-employee relationship extend beyond the last Yes day in pay status? If yes, please explain.

No

I hereby certify that the above information is true and accurate to the best of my knowledge and that I am the individual formally authorized to accept any pension liability for and on behalf of the governing body of this employer. I understand that any error in this certification of service can only be corrected prior to the processing of the members benefit application.
Signature of authorized agent Printed name of authorized agent Title of authorized agent Date (month, day, year)

I have carefully read the form and I understand it. All of the information I have provided and the questions I have answered are full, complete, and true, and no material fact has been concealed or omitted. Pursuant to IC 33-39-7-15, I certify that I am at least sixty-two (62) years of age and have at least eight (8) years of creditable service in this fund.
Signature of applicant Printed name Date (month, day, year)

STEP 5 - CERTIFICATION OF NOTARY PUBLIC STATE OF ______________________________________ COUNTY OF _______________________________ SS:

The above information was subscribed and sworn to before me, a notary public in and for the state and county named, on this ____________ day of _______________________________, 20________.
Signature of notary public County of residence State of residence Printed name of notary public Date commission expires (month, day, year)