Free 53769.FH11 - Indiana

MARITAL STATUS

1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND Reset Form State Form 53769 (10-08)

1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND 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. Complete all information. 3. Include this form with your retirement application.

Name of member (first, middle, last)

Social Security Number *

Marital status (please check one)

Married
Name of spouse (first, middle, last)

Single

Social Security Number *

Date of birth (month, day, year)

Signature of member

Date (month, day, year)

Printed name of member