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Get Claim For Annuity Savings Account Distribution ... - State Of Indiana

IC EMPLOYEES RETIREMENT FUND 143 West Market Street Indianapolis, Indiana 46204-2899 Telephone: (317) 233-4162 Toll free: (888) 526-1687 Fax (317) 234-5922 Toll free fax: (866) 591-9441 * This agency is requesting disclosure of Social Security Numbers / tax identification numbers in accordance with Internal Revenue Code; disclosure is mandatory and this form will not be processed without it. INSTRUCTIONS: 1. Please type or print. Use black ink. 2. Complete all information. 3. This form must.

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