Free 49513.pdf - Indiana

PRELIMINARY ESTIMATE REQUEST RETIREE CHANGE OF BENEFICIARY/ SURVIVOR BENEFICIARY AND/OR RETIREMENT OPTION
State Form 49513 (R3/ 10-07) Approved by State Board of Accounts, 2007

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, Indiana 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Home page: www.in.gov/trf

PRIVAC NOTICE

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.

Important Notice All documentation needed to process any potential changes to your account must accompany this estimate request. This request will not be processed until we have received all documentation. When you receive the estimate, the resulting figures will change upon the next birthday of any individual used in the computation. Thus, if you delay with submitting any paperwork requesting a permanent change to your account, the estimate produced from this request might be inaccurate.
ALL INFORMATION MUST BE COMPLETE BEFORE THIS REQUEST CAN BE PROCESSED. ONCE THIS INFORMATION IS RECEIVED, IT WILL BE REPORTED TO OUR ACTUARIES FOR CALCULATION OF THE ESTIMATE. ONCE WE RECEIVE THE ESTIMATE, WE WILL FORWARD IT ALONG WITH THE ACTUAL APPLICATION THAT IS NECESSARY TO EFFECTUATE ANY CHANGES. IF YOU HAVE QUESTIONS ABOUT THIS PROCESS, PLEASE CONTACT OUR OFFICES.

MODIFIED RETIREMENT INFORMATION IF YOU ARE ELECTING A NEW SURVIVOR BENEFICIARY ON A "B" OPTION OR CHANGING FROM AN "A" OPTION TO A "B" OPTION, PLEASE SEND (IF APPLICABLE):
THE ORIGINAL DEATH CERTIFICATE OF THE FIRST SURVIVOR BENEFICIARY OR IN CASE OF DIVORCE, SEND THE FINAL DIVORCE ORDER OR DECREE THE MARRIAGE CERTIFICATE THE BIRTH CERTIFICATE OF THE NEW SURVIVOR BENEFICIARY

I AM INTERESTED IN CHANGING:

FROM
OPTION A1 A2 A3 B1 B2 B3 A2 A2

TO
OPTION B1 B2 B3 YES NO

At the time of retirement did you select the social security integration (A-4) option? SIGNED: ________________________________ ___________________________ _________________ DATE (month, day, year):

_________________

PRINTED NAME:

TRF NUMBER: ___________________________

SOCIAL SECURITY NUMBER: