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Fillable Printable Form 5094

Fillable Printable Form 5094

Form 5094

Form 5094

615 01 134
Page 1 of 2 SOI-F27
REQUEST TO PURCHASE ADDITIONAL
SERVICE CREDIT
State Form 50941 (R5 / 5-13)
Approved by State Board of Accounts, 2013
INDIANA PUBLIC RETIREMENT SYSTEM
PUBLIC EMPLOYEES’ 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: questions@inprs.in.gov
Web site: www.inprs.in.gov
*This agency is requesting disclosure of Social Security numbers in accordance with Internal Revenue Code 3405; disclosur e is
mandatory and this form cannot be process ed without it.
INSTRUCTIONS
This service may not be used in claiming a retirement benefit until payment in full has been made and you have accumulated ten
(10) years of service, not including a ny purchased service.
1. Remove the instruction pages inclu ded with this form prior to returning the completed form to the Indiana Public Retire ment
System (INPRS).
2. Type or print using black ink. Compl ete all information and place the Member’s name, Social Security number and Pension ID
number at the top of each page as requested.
3. 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.
4. Questions? Call customer service, toll-free, at (888) 526-1687, Monday – Friday, 8 a.m.- 8 p.m. EST.
QUALIFICATIONS
Indiana Code 5-10.2-3-1.2 permits an active member to purchase one year of additional service credit with the Public Employees’
Retirement Fund (PERF or “the Fund”) for each five years of PERF or Teachers’ Retirement Fund (TRF)-covered employment.
In order to purchase this credit you must meet the following criteria:
1. You must be currently employed in a PERF- covered position.
2. You must have at least ten years of PERF- or T RF - covered employment.
PROCEDURE FOR PURCHASE OF SERVICE
If you meet these criteria, complete the MEMBER INFORMATION AND
AUTHORIZATION section of this form. Your current employer must complete the
CURRENT EMPLOYER INFORMAT ION AND CERTIFICATION section of this form.
When both sections are com plete, return the form to INPRS at the address on this
form. PERF will calculate the cost of the service and return a purchase agreement to
you. If you wish to purchase the service, you must complete the agreement and
return it to the address on the agreement together with your payment.
Payment may be made in the form of a trustee-to-trustee transfer, rollover, lump
sum, or in annual installments for a period not to exceed five years. Any installment
shall bear interest at a rate determined b y PERF. Any payments are subject to
applicable Internal Reven ue Code (IRC) limits and the Fund may adjust any
payments in a manner necessary to comply with those l imits. In addition, PERF may
deny any application for the purchase of additional service credit if the purchase
would exceed the limitations under Section 415 of the Internal Revenue Code.
If your years of service are
You are
eligible to
purchase
At least Less than
10 15 2
15 20 3
20 25 4
25 30 5
30 35 6
35 40 7
40 45 8
45 50 9
DISTRIBUTIONS
If you purchase service and elect to withdraw from PERF prior to becoming eligible to receive a monthly benefit, the amount you
have paid plus accumulated interest will be distributed to you.
MEMBER INFORMATION AND A UTH ORIZATION
Member’s name
Social Secu rity number (last 4 digits)*
Pension ID (PID) number
Address
Telephone number with area code
Other telephone number with area code
City
State
ZIP Code
E-mail address
Years of service in a PERF- or TRF-covered position
years
Years of service credit to be purchased
years
I authorize the release of any and a ll information as requested b y PERF pertaining to my application to purchase additional service
credit with the Fund.
Member’s signature
Date (mm/dd/yyyy)
Reset Form
615 01 134
Page 2 of 2 SOI-F27
Member’s name
Social Secu rity number (last 4 digits)*
Pension ID (PID) number
CURRENT EMPLOYER INFORM ATION AND CERTIFICATION
Note: Base annual salary should b e given exclusive of overtime, lump-sum bonuses, travel allowances, etc.
Employer’s name
Employer’s account number
Telephone number with area code
Employee’s position title
Date of hire
(mm/dd/yyyy)
Employee’s annual salary
$
I certify that the employee/member named in this form is employed by us in a PERF-covered position.
Authorized agent’s signature
Authorized agent’s printed name
Date
(mm/dd/yyyy)
INSTRUCTIONS FOR
REQUEST TO PURCHASE ADDIT IONAL SERVICE CREDIT
State Form 50941 (R5 / 5-13)
Approved by State Board of Accounts, 2013
615 01 134Page 1 of 1 SOI-F27
IMPORTANT
This service may not be used in claiming a retirement benefit until payment in full has been made and you have accumulated ten (10)
years of service, not including an y purchased service
1. Remove the instruction pages inclu ded with this form prior to returning the completed form to the Indiana Public Retirement System
(INPRS).
2. Type or print using black ink. Compl ete all information and place the Member’s name, Social Security number and Pension ID
number at the top of each page as requested.
3. 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.
4. Questions? Call customer service, toll-free, at (888) 526-1687, Monday – Friday, 8 a.m.- 8 p.m. EST.
QUALIFICATIONS
Indiana Code 5-10.2-3-1.2 permits an active member to purchase one year of additional service credit with the Public Employees’
Retirement Fund (PERF or “the Fund”) for each five years of PERF or Teachers’ Retirement Fund (TRF)-covered employment.
In order to purchase this credit you must meet the following criteria:
1. You must be currently employed in a PERF- covered position.
2. You must have at least ten years of PERF- or TRF-covered employment.
Entry field Field description
MEMBER INFORMATION AND AUTHORIZATION
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.
Address, City, State, ZIP Code Enter the member’s street or mailing address.
Telephone number/Other telephone number Enter telephone numbers including area codes for the member.
E-mail address Enter the member’s e-mail address, if applicable.
Years of service in PERF- or TRF-covered
position
Enter the number of years the member has been in a PER F- or TRF-covered position
Years of service credit to be purchased Enter the number of years of service credit to be purchase d that corresp onds with the
years of service in the table provid ed on the form.
Member’s signature and date The member must sign and date this section of the form; format = mm/dd/yyyy.
CURRENT EMPLOYER INFORMATION AND CERTIFICATION
Employer’s name Enter the full name of the employer.
Employer account number Enter the employer’s PERF account number .
Telephone number Enter the employer’s telephone numb er with area code.
Employee’s position title Enter the title of the position held by the employee/mem ber.
Date of hire Enter the date of hire for the employee/member; format = mm/dd/yyyy.
Annual salary Enter the employee’s/member’s annual salary. The salary must be the base annual
salary exclusive of overtime, lump-sum bonuses, travel allowances, etc.
Authorized agent’s signature This form must be signed by the emp loyers’ authorized agent.
Authorized agent’s printed name This form must include the printed name of the authorized agent.
Date This form must be dated by the employer’s authorized a gent.
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
www.inprs.in.gov
www.irs.govwww.in.gov/dor
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