Free 24728.FH11 - Indiana

Reset Form

APPLICATION FOR RETIREMENT BENEFITS
STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN
State Form 24728 (R2 / 3-09)

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. 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 Plan 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 visit www.in.gov/perf. MEMBER INFORMATION
Date (month, day, year) Telephone number

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

(

)

Last day at work (month, day, year)

Effective date of retirement benefits: ________________________. This date can be no earlier than the first day of the month following the last day in pay status.
(mm, 01, yyyy)

I, having been sworn, do, on my oath, depose and say that I am the person who made the foregoing statements; that I have carefully read and completed all information on this form; that all completed information is full, complete and true, and no material fact has been omitted therefrom; and that said information is made for presentation to the Board of Trustees of the Public Employees Retirement Fund (PERF) in making claim for a retirement benefit that may be payable to me, under Indiana Code 5-10-5.5 as amended.
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 The normal retirement option for a member is a Joint and Survivor Option. Under this Option, at the time of your death the survivor whom your nominate below is entitled to received fifty percent (50%) of your monthly benefit. You are permitted to nominate any one of the following: 1. your spouse, 2. your unmarried children under the age of eighteen (18), or 3. your parents. An unmarried child designated as beneficiary shall be entitled to draw a survivor benefit only until he/she marries or reaches the age of eighteen (18), whichever comes first.
Name of beneficiary (first, middle, last) Social Security Number of beneficiary * Relationship to member Date of birth of beneficiary (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? If yes, please explain on a separate sheet. Date (month, day, year)

Yes

No