Free 50895.pdf - Indiana

Voluntary Contributions to Annuity Savings Account
State Form 50895 (R/7-04) Approved by the Indiana State Board of Accounts, 2004

Indiana State Teachers' Retirement Fund 150 West Market Street, 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 your form cannot be processed. To obtain your number, send us a written request including your social security number, date of birth, current address, and signature. We will mail you the information.

INSTRUCTIONS: 1. Please TYPE or PRINT. 2. Complete all information. 3. Return the completed form directly to your payroll administrator. MEMBER INFORMATION
First Name MI Last Name

TRF Number (required)

Date

Address (number and street) New Address

City

State

ZIP Code

VOLUNTARY CONTRIBUTION · · · These contributions are limited to ten-percent (10%) of your compensation per pay period. These contributions do not affect your three-percent (3%) mandatory employee contribution. These contributions are post-tax and remain as taxable income for tax purposes. This contribution level direction may be changed at any time in the future.
SELECT THE ADDITIONAL PERCENTAGE OF COMPENSATION THAT YOU WISH TO CONTRIBUTE TO YOUR ANNUITY SAVINGS

·

P LEASE

ACCOUNT ALONG WITH YOUR THREE - PERCENT

(3%)

MANDATORY CONTRIBUTION :

(D ARKEN THE CORRESPONDING C IRCLE )

1% 6%

2% 7%

3% 8%

4% 9%

5% 10%

ENDING VOLUNTARY CONTRIBUTIONS I hereby elect to cease making voluntary contributions to my annuity savings account. SIGNATURE I hereby revoke any previous voluntary contribution directions. I understand that these voluntary contributions are post-tax and remain as taxable income for tax purposes.
Signature Date

RETURN THIS FORM DIRECTLY TO YOUR PAYROLL ADMINISTRATOR.