Free 50798.pdf - Indiana

ASA 5/ASA 6 POST-RETIREMENT ELECTION
State Form 50798 (R2 / 7-07) Approved by State Board of Accounts, 2007

INSTRUCTIONS: 1. 2. Please print or type the requested information in the corresponding boxes below. Place an "X" in the desired Alternative election.

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Home page: http://www.in.gov/trf PRIVACY NOTICE
Your Social Security number is requested by this agency in accordance with the requirements of IRS Code 3405. Disclosure is mandatory; this form will not be processed without this information.

MEMBER INFORMATION
Social Security number TRF number Date of retirement (month, day, year)

First name

Middle initial

Last name

Member's address (number and street or P.O. Box)

Area code and telephone number

(
City State

)
ZIP code

ELECTION FOR ANNUITY SAVINGS ACCOUNT PAYMENT You must select one of the five alternatives described below. You may only select one of the options. This selection cannot be changed by the Fund once the form has been received. ASA 1. I elect to receive the total amount of my Annuity Savings Account paid as a monthly benefit. I understand that I will not receive any distribution from my Annuity Savings Account other than this monthly benefit. Note: By choosing this option, you are increasing your monthly benefit, therefore, you may wish to change your monthly tax withholdings. To do this, please complete the appropriate form(s) or log on to TRF Interactive. ASA 2. I elect to have the total amount of my Annuity Savings Account (less the mandatory withholding for federal income tax and any optional State of Indiana tax withholding indicated on Page 2 of this form) paid directly to me. ASA 3. I elect to have ALL of the taxable portion of my Annuity Savings Account paid in the form of a direct rollover to an Individual Retirement Account (IRA) or a Qualified Retirement Plan that has provisions allowing it to accept the rollover on my behalf. The non-taxable portion will be paid directly to me. (Please indicate your IRA or Qualified Plan information on Page 2). ASA 4. (May be selected only if you want a partial rollover amount of at least $500.) I elect to have a part of the taxable portion of my Annuity Savings Account paid in the form of a direct rollover to an Individual Retirement Account (IRA) or a Qualified Retirement Plan that has provisions allowing it to accept the rollover on my behalf. The non-taxable portion will be paid directly to me. Also, the "part" of the taxable portion of the distribution that is not directly rolled over (less the mandatory withholding for federal income tax and any optional State of Indiana tax withholding indicated on Page 2 of this form) will be paid directly to me. (Please indicate your IRA or Qualified Plan information on Page 2). PARTIAL ROLLOVER AMOUNT (Must be at least $500)

$

ASA 7. I elect to receive a distribution of an amount equal to my tax basis (after-tax contribution) in my Annuity Savings Account balance as it existed on December 31, 1986 and to receive the balance of the account as a monthly benefit. Note: By choosing this option, you are increasing your monthly benefit, therefore, you may wish to change your monthly tax withholdings. To do this, please complete the appropriate form(s) or log on to TRF Interactive.

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For ASA 2 or ASA 4 only
OPTIONAL STATE OF INDIANA TAX WITHHOLDING Indiana income tax withholding for Indiana citizens is optional. If you chose an ASA 2 or ASA 4 and would like to have Indiana State tax withheld at this time, please indicate that amount below. The Indiana tax rate is 3.4%. If you do not indicate an amount below, no deduction will be withheld. I authorize the Indiana State Teachers' Retirement Fund to withhold the following dollar amount for Indiana state tax from the lump sum distribution: $___________________________.

For ASA 3 or ASA 4 only
IDENTIFICATION INFORMATION OF INDIVIDUAL RETIREMENT ACCOUNT OR QUALIFIED RETIREMENT PLAN. I represent that the designated plan is an Individual Retirement Account or Qualified Retirement Plan that has provisions allowing it to accept direct rollovers on my behalf. The Indiana State Teachers' Retirement Fund should make the direct rollover check for the amount shown above payable to: _________________________________________ as trustee of _______________________________________________________ Name of IRA company Member's name

MEMBER AUTHORIZATION I hereby affirm that I am the above named applicant and that I have personally prepared the aforegoing application. I further affirm that I have read and understand the different alternatives listed. I hereby direct the Indiana State Teachers' Retirement Fund (Fund) to process my annuity savings account in the aforegoing selected manner.
Signature of member Printed name of member

Date of signature (month, day, year)

NOTE: If this form is being signed by an Attorney-in-Fact or Legal Guardian, copies of the corresponding Power of Attorney or Guardianship of the Person must accompany this application.

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