Free 53712.FH11 - Indiana

REQUEST FOR ESTIMATE OF BENEFITS / TO PURCHASE SERVICE
JUDGES RETIREMENT SYSTEM
State Form 53712 (R / 2-09) Approved by State Board of Accounts, 2008

JUDGES RETIREMENT SYSTEM 143 West Market Street Indianapolis, Indiana 46204-2899

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* 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. Return the completed form directly to the Judges Retirement System. Do not return the instruction pages.

STEP 1 - MEMBER INFORMATION
Social Security Number * Name of member (first, middle initial, last) Address (number and street, city, state, and ZIP code) Home telephone number Other telephone number E-mail address Date of birth (month, day, year)

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STEP 2 - RETIREMENT INFORMATION

Regular retirement benefits anticipated last day of work (month, day, year)

Disability benefits Social Security onset date (month, day, year)

Anticipated date for beginning benefits (month, 01, year)

STEP 3 - ANTICIPATED BENEFICIARY INFORMATION
Social Security Number * Name of beneficiary (first, middle initial, last) Relationship to member Date of birth (month, day, year)

STEP 4 - SPOUSE INFORMATION
Social Security Number * Name of spouse (first, middle initial, last) Address (number and street, city, state, and ZIP code) Home telephone number Other telephone number E-mail address Date of birth (month, day, year) Date of marriage to member (month, day, year)

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PURCHASE INFORMATION (Complete only if purchasing service.)

Effective date in plan (month, day, year) Date of purchase (month, day, year)

Current salary Amount to be purchased

MEMBER ACKNOWLEDGEMENT
Signature of member Printed name of member Date (month, day, year)

INSTRUCTIONS FOR COMPLETING STATE FORM 53712, REQUEST FOR ESTIMATE OF BENEFITS / TO PURCHASE SERVICE - JUDGES RETIREMENT SYSTEM
IMPORTANT: 1. Remove the form. Do not return these instructions to the Judges Retirement System. 2. Please type or print. Use black ink. 3. Complete all information. 4. Return the completed form directly to the Judges Retirement System at the address below. Important Information We can provide only one (1) estimate of benefits within any twelve (12) month period. Because estimates are prepared based on current information, actual benefits received at the time of retirement may differ. Regular Benefits We can only provide an estimate of benefits once you are within one (1) year of being eligible for retirement. Disability Benefits Determination You are considered to be permanently disabled if the PERF board has received a written certification of your disability by at least two (2) licensed and practicing physicians appointed by the Board. This certification must state that: You are totally incapacitated by reason of physical or mental infirmities from earning a livelihood, and your condition is likely to be permanent. You will be reexamined by at least two (2) physicians appointed by the PERF board at such times designated by the board, but at intervals not exceeding one (1) year. If, in the opinion of these physicians, you have recovered from your disability, your benefits will stop unless you are age sixty-five (65). During the time of your permanent disability, you will earn creditable service toward retirement. If you have eight (8) years of creditable service by age sixty-five (65), you will be entitled to a normal retirement benefit. Amount The annual benefit payable if you become permanently disabled is the product of the salary that was paid to you at the time of your separation from service, multiplied by the percentage shown below: Table B Years of Service Percentage Years of Service Percentage Years of Service Percentage 0-12 50% 16 54% 20 58% 13 51% 17 55% 21 59% 14 52% 18 56% 21 or more 60% 15 53% 19 57% STEP 1: Member Information Members Social Security Number: Enter all nine digits of the Social Security Number. Your application will not be processed without this information. Members Date of Birth: Enter your date of birth as MM/DD/YYYY. If you have not previously furnished proof of your age to the Judges Retirement System, you must submit such documentation along with this form. If you select Option 30, 40, or 50, you are also required to furnish proof of age for your beneficiary. Documents showing the date of birth such as a certified photocopy of a birth certificate, a baptismal or confirmation certificate, or a court decree are acceptable. Attach an English language translation to any foreign language document. Members Name: Enter the first name, middle initial, and last name. Members Address: Enter the full street address, including apartment number or post office box number, if applicable, city, state, and ZIP code to which you would like your estimate sent. Members Telephone Number: Enter the telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail Address: Enter the E-mail address, if available.

STEP 2: Retirement Information Entitlement You will be eligible for normal retirement with full benefits if you: are age sixty-five (65), and have at least eight (8) years of service credit as a judge. You will qualify for early retirement with reduced benefits if you: are between the ages of sixty-two (62) and sixty-five (65), and have at least eight (8) years of service credit as a judge. Your benefit is effective the day following your termination date of employment as a judge. You are entitled to a monthly benefit payable for life in an amount calculated according to Indiana statute (see Table A). To receive your benefit, you may not be receiving, or be entitled to receive, any salary for services currently performed, except for services as a judge pro tempore. Amount If you apply for a retirement benefit and are age sixty-five (65), you are entitled to an amount that equals the product of the salary that you received at the time of your separation from service*, multiplied by the percentage shown below: Table A Years of Service Percentage Years of Service Percentage Years of Service Percentage 8 24% 13 51% 18 56% 9 27% 14 52% 19 57% 10 30% 15 53% 20 58% 11 33% 16 54% 21 59% 12 50% 17 55% 22 or more 60% * Benefit calculations for the 1977 System are based on the current salary of the judges position from which they retired. The 1985 System uses the salary paid to the judge when they retired. After December 31, 2009, benefits paid under the 1985 Judges Retirement System shall be based on the salary being paid for the office that the participant last held, rather then the salary received at separation. If you receive early retirement benefits between the ages of sixty-two (62) and sixty-five (65), your benefits are reduced by one-tenth of one percent (.1%) for each month that your retirement precedes your sixty-fifth (65th) birthday. This reduction does not apply to those judges who are separated from service because of permanent disability. STEP 3: Anticipated Retirement Beneficiary Information Please provide the following information for anyone you anticipate naming as beneficiary for one of the joint and survivor options (Options 30, 40, or 50) at retirement. If you do not provide this information, no estimate will be prepared for the joint and survivor options. Beneficiarys Social Security Number: Enter all nine digits of your beneficiarys Social Security Number. Beneficiarys Date of Birth: Enter your beneficiarys date of birth as MM/DD/YYYY. Beneficiarys Name: Enter the first name, middle initial, and last name. Relationship to Employee: Enter the relationship of your beneficiary to you; e.g. spouse, child, etc. STEP 4: Spouse Information Spouses Social Security Number: Enter all nine digits of your spouses Social Security Number. Spouses Date of Birth: Enter your spouses date of birth as MM/DD/YYYY. Spouses Name: Enter the first name, middle initial, and last name. Date of marriage: Enter the date of your marriage as MM/DD/YYYY. Spouses Address: Enter the full street address, including apartment number or post office box number, if applicable, city, state, and ZIP code. Spouses Telephone Number: Enter the telephone numbers, beginning with area code. If available, please provide separate home and other telephone numbers. E-mail Address: Enter the E-mail address, if available. Member Acknowledgement Please sign, print your name, and date the form.

Once the form has been completed according to these instructions, return the form (DO NOT return the instructions) to the Judges Retirement System at the following address: Judges Retirement System 143 West Market Street Indianapolis, IN 46204

MEMBER NOTE CHANGES TO INFORMATION If you have any changes to any of the information on this form, such as name, address, beneficiary information, etc., please immediately notify the Judges Retirement System at the address above so your estimate can be updated.

HELPFUL INFORMATION Judges Retirement System TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4162 Toll-Free Number 1-888-526-1687 TDD (hearing impaired number) (317) 233-4160 FAX Number (317) 234-5922 Toll-Free FAX Number (866) 591-9441 PERF on the Internet: www.in.gov/perf JUDGES RETIREMENT SYSTEM MEMBER HANDBOOK (latest edition) Internal Revenue Service TELEPHONE NUMBERS: Toll-Free Number 1-800-829-1040 TDD (hearing impaired number) 1-800-829-4059 TeleTax 1-800-829-4477 IRS website: www.irs.gov IRS PUBLICATION 575, PENSION AND ANNUITY INFORMATION IRS PUBLICATION 590, INDIVIDUAL RETIREMENT ARRANGEMENTS Indiana Department of Revenue (DOR) TELEPHONE NUMBERS: Indianapolis & vicinity (317) 233-4018 TDD (hearing impaired number) (317) 233-4952 Individual Income Tax Questions (317) 232-2240 Outside of Indianapolis See DOR website DOR FAX Number (317) 233-2329 DOR website: www.in.gov/dor