*Please be sure to include your signature and social security number.

IRTAPAC Donation Form
828 S. Second St., 4th Floor • Springfield, IL 62704 • 1-800-728-4782   
 
IRTAPAC Donation – I hereby authorize the Teachers’ Retirement System to DEDUCT my IRTAPAC donation in monthly installments of $1.00.


(Signature Required)
 
 
Please print or use your return address label.
Social Security #  Required:                                                                                                     ______________
          CAN USE LAST FOUR NUMBERS                    NAME   LAST   
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