Free 52595.pdf - Indiana

IRREVOCABLE PAYROLL DEDUCTION AUTHORIZATION
State Form 52595 (R / 6-08)

PRIVACY NOTICE
All Social Security numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory and this form will not be processed without this information.

Approved by State Board of Accounts, 2008

For Voluntary Pre-Tax Annuity Savings Account Contributions
INSTRUCTIONS: 1. Please TYPE or PRINT. Use black ink. 2. Send the completed form directly to the Teachers' Retirement Fund (TRF).

STEP 1: APPLICANT INFORMATION Social Security number __ __ __ - __ __ - __ __ __ __ First name Mailing address (number and street) City Telephone number Date of hire (month, day, year) State E-mail address PERF service, if any ZIP code TRF number Middle initial Last name

STEP 2: PAYROLL DEDUCTION AUTHORIZATION (Select one only) I hereby direct my employer to make the following pre-tax deduction from my salary per pay period for the purpose of making additional contributions to my Annuity Savings Account and to remit these deductions to TRF. I certify that the total of my pre-tax and post-tax voluntary contributions does not exceed 10% of my salary per pay period. I understand that once this authorization is processed, my pre-tax deduction cannot be changed or canceled, so long as I am employed with this employer.

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Member signature

Printed name

STEP 3: EMPLOYER INFORMATION (Must be completed by your employer) Employer name Authorized signature Printed name School Unit number

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STEP 4: MEMBER-EMPLOYER PAYROLL DEDUCTION AGREEMENT (Must be completed by you and your employer)
I attest that I am a member in active employment covered by the Teachers' Retirement Fund and that I am entitled under the provisions of IC 5-10.2-3-2(c) to make contributions to my Annuity Savings Account in addition to the mandatory contribution under IC 5-10.2-3-2(b), and I desire to make those contributions through payroll deductions. I understand my election period to make these contributions on a pre-tax basis starts on September 1 following the plan year in which I completed five years of creditable service, and ends two years later, on August 31 of the second calendar year following the opening of the election period. I understand that the Teachers' Retirement Fund has adopted rules allowing me to direct my Employer to "pick-up" these additional contributions under the tax deferral provisions of federal Internal Revenue Code Section 414(h)(2) and that tax deferral of my additional contributions due to the Teachers' Retirement Fund requires this irrevocable payroll deduction authorization. I further understand that my Employer has agreed to participate in the "pick-up" of these additional contributions. I hereby direct my Employer to make the selected deduction from my salary per pay period for the purpose of making additional contributions to my Annuity Savings Account and to remit them to the Teachers' Retirement Fund beginning with the pay period immediately after the Employer receives this authorization form and continuing until I terminate employment, retire or die. With respect to this payroll deduction, I understand the following: This is an irrevocable payroll deduction authorization. The salary my Employer will use to calculate this contribution is the same as the salary that my Employer is reporting to the Teachers' Retirement Fund for purposes of my mandatory contribution and benefit calculations. Nothing herein shall prevent me from paying any amount of permissible additional contributions not covered by this irrevocable deduction authorization with after-tax dollars. However, the total amount contributed by me (including any amounts contributed on my behalf, but excluding mandatory contributions) may not exceed ten percent (10%) of my compensation. The investment of the additional contributions shall be made in the same manner and percentage as the investment of my mandatory contributions. The distribution of the additional contributions shall be made in the same manner as all other distributions from my Annuity Savings Account. After the execution of this irrevocable deduction authorization, I do not have the option of receiving the deduction amounts directly instead of having them paid by my Employer to the Teachers' Retirement Fund. These contributions are being picked-up by my Employer, and, as a result, although designated as employee contributions, they are being paid directly to the Teachers' Retirement Fund in lieu of contributions by me. While this agreement is in effect, I understand that with respect to the amount of the contributions designated herein, the Teachers' Retirement Fund will only accept payment from my Employer and not directly from me. When I terminate employment with my Employer or die, this binding, irrevocable payroll deduction authorization shall expire. The payroll deduction authorization is not effective until signed by me and an authorized representative of my Employer. The pick-up is only applicable to contributions to the extent the contribution is deducted from compensation earned for services after the effective date of the pick-up.

Member signature Printed name Date (month, day, year)

Employer agent signature Printed name Date (month, day, year)

IRREVOCABLE PAYROLLL DEDUCTION AUTHORIZATION For Voluntary Pre-Tax Annuity Savings Account Contributions

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IMPORTANT!
In order to complete your application, you must send this form to TRF at the following address so we can complete Step 5:

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204

WE WILL RETURN THE FORM TO YOUR PAYROLL DEPARTMENT ONCE STEP 5 IS COMPLETE. IF YOU ARE A STATE EMPLOYEE, THIS FORM WILL BE FORWARDED TO THE STATE AUDITOR FOR PROCESSING.

STEP 5: TRF VERIFICATION OF SERVICE AND ELIGIBILITY FOR TRF USE ONLY! Verification Verified Employer Participation Verified Eligibility Service Verified Eligibility Window Initials Date

Approved for Payroll Deduction Signature Printed name

Yes

No

Date (month, day, year)

IRREVOCABLE PAYROLLL DEDUCTION AUTHORIZATION For Voluntary Pre-Tax Annuity Savings Account Contributions

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