Fillable Printable Form 52696
Fillable Printable Form 52696
Form 52696
Page 1 of 1 SOI-F89
APPLICATION FOR
RETIREMENT BENEFITS
State Form 52696 (R5 / 5-13)
INDIANA PUBLIC RETIREMENT SYSTEM
PROSECUTING ATTORNEYS’
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; disclosure is mandatory and
this form will not be pro cessed w ithout 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 above.
2. Type or print using black ink. Compl ete all information and place the Member’s name, Social Securit y number and Pension ID
number at the top of each page as requested.
3. If not already submitted to INPRS, a copy of both the member’s and b eneficiary’s birth certificate must be included with this form.
Documents showing the date of birth and parents such as a copy of a birth certificate, or a registration from the public health
department, or other governmental entity; or a court decree obtained under IC 34-28-1 and certified by the clerk of the court; or
other evidence relating to date of birth, subject to board a pproval, are acceptable.
4. Include an English translatio n of all forei gn documents.
5. 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.
6. Questions? Call customer service, toll-free, at (888) 526-1687, Monday – Friday, 8 a.m.- 8 p.m. EST .
MEMBER INFORMATION
Name
Social Security number
(last 4 digits)*
Pension ID (PID) number
Address (number and street)
City
State
ZIP Code
Date of application (mm/dd/yyyy)
Date of birth
(mm/dd/yyyy)
RETIREMENT DATE
Effective date of retirement benefits: This date can be no earlier that the first day of the month
following the last day in pay status, but not prior to six (6) months before the Public Employees'
Retire me nt Fund B oa rd of Tru s tee s receives your completed application. If your benefits will not
begin the month following your termination from employment, please specify the future date.
Retirement date (mm/01/yyyy)
SPOUSE INFORMATION
Name
Social Security number*
Date of birth
(mm/dd/yyyy)
EMPLOYER CERTIFICATION OF LAST DAY IN PAY STATUS
Federal law proh ibi t s the Prosecu ting Attorneys' Re tire me nt Fund (PARF) from making di stribu tions fro m the Fund prior to
"sepa ration from empl oymen t."
Uninterrupted service in any capacity or reemployment that is a continuation of employment will
prevent PARF from making distributions to the employee from the Fund.
Last day in pay status is the last day for which this employee was entitled to receive his or her regular wages. It will typically not be
the last check date. Regular wages paid may include pay for a day worked, a sick day, vacation da y or another paid l eave permitted
under your personnel p olicy. Th e last day in pay status is needed to process this member's benefit.
Last day in pay status (mm/dd/yyyy)
Did the employer-emplo yee relationship extend be yond the last day
in pay status?
Yes No
If yes, please explain:
I hereby certify that the above information is true an d accurate to the best of my knowledge and that I am the individual formally
authorized to accept any pension liability for and on beh alf of the govern ing body of this e mplo yer. I understand that any error in this
certification of service can only be corrected prior to the processing of the member's benefit application.
Signature of authorized agent Date (mm/dd/yyyy)
Printed name
Title
Reset Form
Page 2 of 1 SOI-F89
Name
Social Security number (last 4 digits)*
Pension ID (PID) number
DECLARATION
I have carefully read the form and I understand it. All of the information I have provided and the questions I have ans wered are
full, complete, and true, and no material fact has been co ncealed or omitted.
Pursuant to IC 33-39-7-15, I certify that I am at least sixty-two (62)years of age and have at least eight (8) years of creditable
service in this fund.
Applicant’s signature Date (mm/dd/yyyy)
Printed name
NOTARY PUBLIC CERTIFICATION
State of _________________________ ________
SS:
County of _____________________ __________
Before me the undersigned, a Notary Publ ic for __________________ _________ County, State of __________________________,
Officer’s county of residence Officer’s state of residence
personally app eared ____________ ___________________________ a nd he/she, being first dul y s worn by me upon his/her oath,
Name of person
say that the facts alleged in the foregoing instrument are true. SEAL
Signed and sealed this _______ day of _______ _______, 20_______.________________________ _______________ _________
Signature
My commission expires: _______________ _______________ ______ ________________________ _______________ _________
Date (mm/dd/yyyy)Name of officer (printed or typed)
INSTRUCTIONS FOR
APPLICATION FOR RETIREMENT BENEFITS
State Form 52696 (R5 / 5-13)
Page 1 of 1 SOI-F89
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 above.
2. Type or print using black ink. Compl ete all information and place the Member’s name, Social Securit y number and Pension ID
number at the top of each page as requested.
3. If not already submitted to INPRS, a copy of both the member’s and b eneficiary’s birth certificate must be included with this form.
Documents showing the date of birth and parents such as a copy of a birth certificate, or a registration from the public health
department, or other governmental entity; or a court decree obtained under IC 34-28-1 and certified by the clerk of the court; or
other evidence relating to date of birth, subject to board a pproval, are acceptable.
4. Include an English translatio n of all forei gn documents.
5. 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.
6. Questions? Call customer service, toll-free, at (888) 526-1687, Monday – Friday, 8 a.m.- 8 p.m. EST .
Entry field
Field description
MEMBER INFORMATION
Name Enter the member’s complete name.
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.
Date of application Enter the application date; format = mm/dd/yyyy.
Date of birth Enter the member’s date of birth; format = mm/dd/yyyy.
RETIREMENT DATE
Retirement date
Enter the member’s retirement date beginning on the first day of the month; format –
mm/dd/yyyy.
SPOUSEINFORMATION
Name Enter the spouse’s complete name.
Social Security number Enter the spouse’s Social Security number.
Date of birth Enter the spouse’s date of birth; format = mm/dd/yyyy.
EMPLOYER CERTIFICATION OF LAST DAY IN PAY STATUS
Last day in pay status Enter the last day in pay status; format – mm/dd/yyyy.
Employer-employee relationship Choose yes or no.
Explanation Enter an explanation if yes is answered above.
Applicant signature and date This section must be signed and dated by the authorized agent; format = mm/dd/yyyy.
Printed name of applicant Enter the authorized agent’s printed name.
Title Enter the authorized agent’s title.
DECLARATION
Member signature and date This section must be signed and dated by the member; format = mm/dd/yyyy.
NOTARY PUBLIC CERTIFICATION
This form must be notarized before it can be processed by INPRS. Take the form to a Notary Publicwith 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 notar y must then complete the NOTARY PUBLIC CERTIFICATION section of the form and affix the
Notary’s seal.
HELPFUL INFORMATION
INPRS/PARF 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
