Free 52332.pdf - Indiana

REQUEST FOR ROLLOVER ACCOUNT BENEFICIARY DESIGNATION CHANGE
State Form 52332 (7-05) Approved by State Board of Accounts, 2005

Indiana State Teachers' Retirement Fund 150 West Market St., Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544 Home Page: http://www.in.gov/trf

PRIVACY NOTICE Your TRF number is required on this form. Without it our agency cannot process your request. To obtain your number, please send a written request and include your Social Security number, date of birth, current address and signature. We will mail you the information.

INSTRUCTIONS TO MEMBERS

Please use this form to designate or change a beneficiary for your rollover account. If you elect multiple beneficiaries, be sure to designate "Primary" or "Secondary" for each person listed.

PLEASE USE BLACK INK ONLY
Name of member (first, middle initial, last) MEMBER IDENTIFICATION TRF account number (required) Marital status Married Single

CHANGE OF BENEFICIARY

NOTE: A "Primary" beneficiary will receive all benefits due upon the member's death. Multiple surviving "Primary" beneficiaries will receive equal shares. A "Secondary" beneficiary will receive all benefits upon the member's death, only if all designated "Primary" beneficiaries predecease the member. Multiple "Secondary" beneficiaries will also receive equal shares. The option to choose a beneficiary must be signed by a witness. All information on this form will be used for your "Rollover Account" only. No changes to any other account will be made using this form. THE INFORMATION LISTED BELOW REPLACES ALL INFORMATION LISTED ON PREVIOUS FORMS.
DESIGNATION
PRIMARY 1. SECONDARY PRIMARY 2. SECONDARY PRIMARY 3. SECONDARY PRIMARY 4. SECONDARY PRIMARY 5. SECONDARY

SOCIAL SECURITY NUMBER

NAME OF BENEFICIARY (First, Middle Initial, Last)

DATE OF BIRTH

RELATIONSHIP

MEMBER ATTESTS THAT ALL CHANGES ARE TRUE TO THE BEST OF HIS / HER KNOWLEDGE Member signature: Date signed (month, day, year):

Witness signature (any person other than an above named beneficiary):

Date signed (month, day, year):