Free 11403.FH11 - Indiana

MEMBERSHIP RECORD

STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN
State Form 11403 (R2 / 10-08)

STATE EXCISE POLICE, GAMING AGENT, GAMING CONTROL OFFICER & CONSERVATION ENFORCEMENT OFFICERS RETIREMENT PLAN 143 West Market Street Indianapolis, Indiana 46204-2899

Reset Form

* 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. 2. 3. 4.

Please type or print. Use black ink. Complete all information. Remember to put your name and Social Security Number at the top of every page. Submit a copy of the members birth certificate, which is required for this record to be processed. Return the completed form directly to the State Excise Police, Gaming Agent, Gaming Control Officer and Conservation Enforcement Officers Retirement Plan at the above address.

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

Name of member (first, middle initial, last)

Gender

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

Female

Home telephone number

Other telephone number

E-mail address

(

)

(

)
Beginning date of employment (month, day, year)

Name of department

STEP 2 - FAMILY DATA
Name of spouse (first, middle initial, last) Date of birth (month, day, year)

Name of dependent (first, middle initial, last)

Date of birth (month, day, year)

Name of dependent (first, middle initial, last)

Date of birth (month, day, year)

Name of dependent (first, middle initial, last)

Date of birth (month, day, year)

Name of dependent (first, middle initial, last)

Date of birth (month, day, year)

Name of dependent (first, middle initial, last)

Date of birth (month, day, year)

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Name of member (last, first, middle initial)

Social Security Number *

STEP 3 - SERVICE DATA - List all service rendered as a Conservation Officer, Gaming Agent, Gaming Control Agent, or Excise Police Officer. Name of Department Name of Position Start Date (month, day, year) End Date (month, day, year)

CERTIFICATION I submit the above information and hereby agree to make contributions by law. I hereby certify that the service listed is correct to the best of my knowledge and belief.
Signature of employee Date (month, day, year)

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Name of member (last, first, middle initial)

Social Security Number *

STEP 4 - DESIGNATION OF BENEFICIARY If a surviving widow, parent, or child under eighteen (18) years of age is nominated as a beneficiary, he or she may be entitled to survivor benefits. It is important that you nominate one primary beneficiary and one contingent beneficiary. In accordance with the provisions of the act governing the State Excise Police, Gaming Agent and Conservation Officers Retirement Plan, I hereby nominate the following person as my primary beneficiary under the Retirement Plan.
Full name of primary beneficiary (first, middle, last) Relationship (if any)

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

I hereby nominate the following person as my contingent beneficiary under the Retirement Plan.
Full name of contingent beneficiary (first, middle, last) Relationship (if any)

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

If the beneficiary herein nominated shall survive me, he or she shall receive all funds due from my participation in the State Excise Police, Gaming Agent, Gaming Control Officer and Conservation Officers Retirement Plan. If the beneficiary shall not survive me, then the contingent beneficiary shall receive such funds. If neither survive me, then the beneficiary shall be my estate. I reserve the right to change the beneficiary or contingent beneficiary at any time by filing written notice of such change, duly witnessed, with the Board of Trustees of the Public Employees Retirement Fund of Indiana.
Signature of employee Date (month, day, year)

STEP 5 - CERTIFICATION OF PRESENT EMPLOYER I hereby certify that, according to the evidence submitted to me, the foregoing statements and record of service listed is correct to the best of my knowledge and belief.
Signature of authorized individual Date (month, day, year)

Printed name of authorized individual

Title of authorized individual

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