State Form 29211 - Request For Estimate Of Benefits

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PUBLIC EMPLOYEES’ RETIREMENT FUND

143 West Market Street

REQUEST FOR ESTIMATE OF BENEFITS

Indianapolis, Indiana 46204-2899

State Form 29211 (R5 / 10-08)

Reset Form

* This agency is requesting disclosure of Social Security 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. Return the completed form directly to PERF. Do not return the instruction pages.

STEP 1 - MEMBER INFORMATION

Social Security Number *

Date of birth (month, day, year)

Name of member (first, middle initial, last)

Address (number and street, city, state, and ZIP code)

Home telephone number

Other telephone number

E-mail address