Form F-1 - Membership Application - Kentucky Teachers' Retirement System printable pdf download

Form F-1 - Membership Application - Kentucky Teachers' Retirement System

MEMBERSHIP APPLICATION

Kentucky Teachers' Retirement System

479 Versailles Road

Frankfort, KY 40601-3800

Ph. (502) 848-8500

Do Not Use this form if you are a KTRS RETIRED Member!

Retirees Returning to Work Need to Complete Form F1RET which is the:

Retiree Membership Application KTRS Retiree Returning to a KTRS Covered Position

This application is one of the most important documents you will complete in your

teaching/employment career. Once employed in a position covered by KRS Chapter 161

your membership in Kentucky Teachers' Retirement System (KTRS) entitles you to

valuable benefits. These benefits include survivor benefits and a $2,000 life insurance

benefit available to your beneficiary upon your death. It is vital that you follow the

directions and complete this application accurately. Please type or print all requested

information except for signatures. Delay in sending this application to KTRS may

jeopardize your survivor's eligibility for benefits.

INSTRUCTIONS

It is important that you carefully read the instructions

before completion of this form.

(For questions concerning this form, please call KTRS.)

PART I

MEMBER INFORMATION: Use your full name, not initials.

The name

provided should be the same as the name used by your employer. A copy

of your social security card issued by the Social Security Administration

and bearing your signature (not the stub that accompanies the card) is

needed to verify the accuracy of this number. Your date of birth should

be numerically listed (August 10, 1975 should be 08/10/1975). Address

should be a permanent address. Any future change of name or address

must be in writing to KTRS.

PART II

SPOUSE AND DEPENDENT INFORMATION (If applicable): Format should

follow instructions used for member information. Check to assure accuracy

of social security numbers and birthdate information.

PART III

MEMBER EMPLOYMENT INFORMATION: Please answer questions as

indicated.

See back of page for additional instructions.

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F-1

Form F-1 - Membership Application - Kentucky Teachers' Retirement System