Fillable Printable Form 49290

Form 49290

Page 1 of 1

DATE OF BIRTH AFFIDAVIT

State Form 49290 (R5 / 1-16)

INDIANA PUBLIC RETIREMENT SYSTEM

PUBLIC EMPLOYEES’ RETIREMENT FUND

TEACHERS’ RETIREMENT FUND

1 North Capitol Avenue, Suite 001

Indianapolis, IN 46204-2014

Telephone: (888) 526-1687 (Toll-free)

Fax: (866) 591-9441 (Toll-free)

E-mail: [email protected]

Web site: www.inprs.in.gov

*This agency is requesting disclosure of Social Security numbers in accordance with Internal Revenue Code 3405; disclosure is

mandatory and this form cannot be process ed without it.

INSTRUCTIONS

1. Remove the instruction pages inclu ded with this form prior to returning the completed form to the Indiana Public Retire ment

System (INPRS) at the address shown on this form.

2. Type or print using black ink. Complete al l information as requested.

3. This form must be notarized and the notary’s seal must be visible and readabl e.

4. This completed form may be delivered to the lobby of INPRS at the address indic ated o n the form. Lobby hours are 8 a.m. to 5

p.m. on weekdays. The agency is closed on weekends and holidays, including all State- designated holidays.

5. Questions or changes? Call customer service, toll-free, at (888) 526-1687, Monday – Frid ay, 8 a.m.- 8 p.m. EST.

MEMBER INFORMATION

Member’s name

Social Security number* (last 4 digits)

Pension ID (PID) number

AFFIDAVIT

This affidavit is being made by (check one): Member Beneficiary Survivor

Affiant’s name

Social Security number*

Date of birth

(mm/dd/yyyy)

I hereby affirm that I do not have any of the following doc uments or any two documents identified in 35 IAC 1.2-5-17. This regulation

is available online at http://www.in.gov/legislative/iac/T00350/A00012.PDF

. (If you do not have access to 35 IAC 1.2-5-17, please call

a PERF representative to request a copy.)

1. A birth certificate or registration from the public health department or other governmental entity,

2. A court decree obtained under IC 34-28-1 and certified by the clerk of the court,

I further affirm that I understand the Indiana Public Retirem ent System (INPRS) will use the birth date written on this form as my date

of birth in order to determine a benefit entitle ment.

Affiant’s signature

Date

(mm/dd/yyyy)

NOTARY PUBLIC CERTIFICATION

State of _________________________________

SS: SEAL

County of _______________________________

Before me the undersigned, a Notary Publ ic for __________________ _________ Count y, State of _____________ _____________,

Officer’s county of residence Officer’s state of residence

personally app eared _______________________________________ and he/she, being first duly sworn by me upon his/her oath,

Name of person

say that the facts alleged in the foregoing instrument are true.

Signed and sealed this _______ day of _______ _______, 20_______. ________________________ ________________________

Signature

My commission expires: ___________________________ _________ ________________________ ________________________

Date (mm/dd/yyyy) Name of officer (printed or typed)

35 IAC 14-7-3

Reset Form

INSTRUCTIONS FOR

DATE OF BIRTH AFFIDAVIT

State Form 49290

Page 1 of 1

IMPORTANT

1. Remove the instruction pages inclu ded with this form prior to returning the completed form to the Indiana Public Retire ment System

(INPRS) at the address shown on this form.

2. Type or print using black ink. Complete al l information as requested.

3. This form must be notarized and the notary’s seal must be visible and readabl e.

4. This completed form may be delivered to the lobby of INPRS at the address indic ated o n the form. Lobby hours are 8 a.m. to 5

p.m. on weekdays. The agency is closed on weekends and holidays, including all State- designated holidays.

5. Questions or changes? Call customer service, toll-free, at (888) 526-1687, Monday – Frid ay, 8 a.m.- 8 p.m. EST.

Entry field Field description

MEMBER INFORMATION

Member’s name Enter the complete name of the member.

Social Security number Enter the last 4 digits of the member’s Social Security number.

Pension ID (PID) number Enter the member’s Pension ID (PID) number.

FFIDAVIT

This affidavit is being made by

Check one from Membe

, Beneficiary, or Survivo

Affiant’s name Enter the complete name of the affiant.

Social Security number Enter the last 4 digits of the affiant’s Social Security number.

Date of birth Enter the affiant’s date of birth; format = mm/dd/yyyy.

Affiant’s signature The affiant must sign and date this form.

Date The affiant must sign and date this form; format = mm/dd/yyyy.

NOTARY PUBLIC CERTIFICATION

This form must be notarized before it can be process ed by INPRS. Take the form to a Notary Public with an active commission. The

Notary will require that you swear or affirm that you are th e named person on the form. You will be required to sign and date the form

in the Notary’s presence. The notary must then complete the NOTARY PUBLIC CERTIFICATION section of the form and affix the

Notary’s seal.

HELPFUL INFORMATION

INPRS/PERF INTERNAL REVENUE SERVICE

INDIANA DEPARTMENT OF REVENUE

Telephone

numbers

(888) 526-1687 Toll-free (800) 829-1040 Toll-free (317) 233-4018 Indianapolis local

(866) 591-9441 Fax Toll-free (800) 829-4477 TeleTax (317) 232-2240 Tax questions

(800) 829-4059 TDD (hearin g

impaired)

(317) 233-4952 TDD (hearin g

impaired)

(317) 233-2329 Fax

Web site