Free 34413.FH11 - Indiana

MEMBERSHIP RECORD
State Form 34413 (R7 / 10-08)

Reset Form

PUBLIC EMPLOYEES RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2899 Fax: (317) 234-5922

* 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. Incomplete forms will be returned. 3. Return the completed form to PERF by mail or fax.

STEP 1 - ENROLLMENT INFORMATION
Social Security Number * Date of birth (month, day, year)

Name (first, middle initial, last)

Gender

Current marital status

Male
Address (number and street, city, state, and ZIP code)

Female

Single

Married

Home telephone number

Other telephone number

E-mail address

(

)

(

)

STEP 2 - FOR EMPLOYER USE ONLY
Date of full-time employment in this PERF-covered position and start of mandatory contributions (month, day, year)

Position or title

Is this an elected position?

Has this employee been a member of PERF before?

Yes
Name of employer

No

Yes

No

Address of employer (number and street, city, state, and ZIP code)

Telephone number of employer

Account number of employer

(

)
I have verified that the Social Security Number on this form is the same as the number used on our payroll and reported to the Internal Revenue Service for tax purposes.

Signature of authorized agent

Date (month, day, year)

Printed name of authorized agent

Title of authorized agent

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Name of member (last, first, middle initial)

Social Security Number *

STEP 3 - BENEFICIARY INFORMATION (Attach additional copies of this page if necessary.) Additional pages are attached.
Name of beneficiary (last, first, middle initial) Date of birth (month, day, year) Address (number and street, city, state, and ZIP code) Name of beneficiary (last, first, middle initial) Date of birth (month, day, year) Address (number and street, city, state, and ZIP code) Relationship to member Social Security Number or tax identification number * Relationship to member

Yes

No
Social Security Number or tax identification number *

Primary Beneficiary or Beneficiaries

Contingent Beneficiary or Beneficiaries
Name of beneficiary (last, first, middle initial) Date of birth (month, day, year) Address (number and street, city, state, and ZIP code) Name of beneficiary (last, first, middle initial) Date of birth (month, day, year) Address (number and street, city, state, and ZIP code) Relationship to member Social Security Number or tax identification number * Relationship to member Social Security Number or tax identification number *

In accordance with the provisions of Indiana Code § 5-10.2-3, I designate my beneficiary or beneficiaries for my annuity savings account as shown above. I understand that this designation of beneficiary supersedes and replaces any prior designation of beneficiary or beneficiaries for my annuity savings account that may have been made. If the primary beneficiary or beneficiaries herein designated survive me, they shall receive the funds, if any, that are payable by the fund to a designated beneficiary. If the primary beneficiary or beneficiaries do not survive me, then the contingent beneficiary or beneficiaries shall receive such funds. If none survive me, then the beneficiary shall be my estate. I reserve the right to change the primary or contingent beneficiaries at any time prior to distribution of my annuity savings account by filing a Change of Beneficiary form with the Board of Trustees of the Fund. Such a change must be received and accepted by the fund for it to become effective.
Signature of member Printed name Date (month, day, year)

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