Verification of Service and Salary_TRS Form 22I

*+22I*
TEACHER RETIREMENT SYSTEM OF TEXAS
1000 Red River Street, Austin, Texas 78701-2698
Telephone (512) 542-6400 or 1-800-223-8778
www.trs.state.tx.us
TRS 22I
Rev. 08-11
VERIFICATION OF SERVICE AND SALARY
Name of Member (please print)
Social Security No.
Current Mailing Address of the Member
TRS MEMBER: This form is to be completed and signed by a school business official of the TRS reporting
entity where the service being verified was rendered. After the form has been completed and signed by a
school official, you must sign where indicated on the reverse side of this form, before sending the form
to the Teacher Retirement System (TRS).
SCHOOL OFFICIAL: Do not include more than one school year on this form. If more than one school
year is being verified, use a separate form for each year. Initial here
if more than one form is
being completed. Please complete all requested information; do not leave information blank. If records are
unavailable or the information is unknown, indicate in the space provided. Verification must be based on
records created at or near the time of service. An affidavit based on memory is not sufficient. After
completing this page, read and sign the "Certification of School Official" on the reverse. Note, your signature
must be notarized. Return this form to the member after completion. Do not return this form to TRS.
SECTION A: See instructions on reverse before completing this section.
1. School year during which service was rendered:
2. Number of days worked or on paid leave:
3. Gross salary paid for this period:
4. Position or job title:
5. Name under which person rendered this service:
6. Was this service rendered as an employee or as an independent contractor?
SECTION B: See instructions on reverse before completing this section.
1. Was employment for one-half or more of the standard workload? YES
NO
2. Was the salary rate comparable to the rate of compensation paid to other persons employed in similar
positions at the time? YES
NO
3. If the answer to question #2 in this section is "No", was the person's customary employment for at least
20 hours per week, each week, for a period of at least four and one-half months in one school year?
Yes
No
4. Employment dates for the first semester: Beginning
Ending
Semester dates for the first semester: Beginning
Ending
5. Employment dates for the second semester: Beginning
Ending
Semester dates for the second semester: Beginning
Ending
SECTION C: In addition to Sections A and B, this section must be completed if the service being
verified was rendered in higher education. Leave this section blank if the service being verified
was rendered in a public school district or open enrollment charter school.
1. Was the employment verified above contingent upon the person's enrollment as a student in your
institution? YES
NO
2. Did the person named above participate in the Optional Retirement Program during the year listed?
YES
NO
Reverse of Form
TRS 22I
Rev. 08-11
INSTRUCTIONS FOR SCHOOL OFFICIAL: This form must be completed and signed by the current TRS reporting
official of the Texas public educational institution where the service was rendered or by the school's payroll manager, payroll
supervisor, financial officer, or superintendent. TRS may not accept the form if it is not signed by an appropriate official. All
information in Sections A and B on the front side of this form must be completed. In addition, Section C must be completed if
the service being verified was rendered in an institution of higher education. In all cases, the "Certification of School Official"
below must be completed. This form is not to be used to verify substitute service, worker's compensation payments, or out-ofstate service.
Sections 825.403 and 825.505 of the Texas Government Code grant TRS the right to audit records used for documentation of
service and salary. By completing this form and signing the "Certification of School Official," you agree to produce the records
used to verify the service and salary listed upon request of the retirement system.
Certification of School Official: I certify that records created at or near the time of service in my office show that the
person named on this form performed the service listed on this form and show that all other information provided in Sections
A and B is true and correct. I further certify that I am currently employed in the reporting entity named below and that this
reporting entity is a TRS covered educational institution. The reporting entity agrees to produce records used to verify the
service and salary reported to TRS upon request as required in Sections 825.403 and 825.505, Texas Government Code.
Signature of School Official
Title of School Official
Printed Name of School Official
Name of Texas Public Educational Institution
Date Signed
(
)
Telephone Number
Notarization of School Official Signature:
STATE OF
COUNTY OF
Before me, a notary public, on
(date) personally appeared
(school official)
known to me to be the person whose name is subscribed to the foregoing document and, being by me first duly sworn,
declared that the statements therein are true and correct.
GIVEN under my hand and official seal this the
day of
, Year
(SEAL)
Month
Signature of Notary Public
RETURN THIS COMPLETED FORM TO THE MEMBER. DO NOT RETURN THIS FORM TO TRS.
INSTRUCTIONS FOR MEMBER: Employment that is eligible for TRS membership is employment in a Texas public educational institution for at least
one-half the standard workload, paid at a rate comparable to someone employed in a similar position. To establish service credit, prior to the
2011-12 school year, a person must have served in an eligible position, by an eligible employer, for a period of at least four and one-half months, a full
semester of more than four months, or, in some circumstances, 90 days in one school year. For the 2011-12 and later school years, a member must work
or be on paid leave for at least 90 days in one school year to receive a year of service credit. In addition, if there is no equivalent full time position of a
given position, the minimum number of hours required per week that will qualify the position for TRS membership is 15. Take this form to the Texas public
school where you rendered service for completion of Sections A, B, and C (if applicable) and the "Certification of School Official." After the school official
has completed all information, sign below and return this form to TRS. TRS will determine, based on the information provided by the school official and
applicable laws and rules, whether eligible service is indicated. Receipt of this form by TRS does not constitute a guarantee that service credit will be
granted by the retirement system.
If TRS determines that the employment and/or compensation is eligible for TRS credit, TRS will send you a bill for the amount due. All deposits and fees
due must be paid in full before this service or compensation can be used in the calculation of benefits or to determine your eligibility for
benefits. The cost increases each year the amount due remains unpaid.
All unreported service rendered or compensation paid prior to September 1, 2011 must be verified no later than September 1, 2016. Beginning with the
2011-12 school year, unreported service or compensation must be verified no later than five years after the end of the school year in which the service
occured or the compensation was paid. Service and/or compensation that is not verified within the required timeframe will not be eligible for purchase and
cannot be used in determining eligibility for or the calculation of any benefits. Verification of unreported service and/or compensation cannot be accepted
after you have retired and TRS has issued your first retirement check or after the effective date of your election to participate in the Deferred Retired
Option Plan (DROP).
The cost to purchase credit for unreported service rendered and/or compensation paid prior to September 1, 2011 will increase to the acturial present value
at the time of purchase, if payment in full or a properly completed installment agreement is not received by August 31, 2013. This represents a substantial
increase in cost. All unreported service rendered or compensation paid on or after September 1, 2011 will require payment of the actuarial present value at
the time of purchase. Purchase of this service or compensation credit is optional.
I have read the "Instructions for Member" and understand that, if TRS determines that the service or compensation is eligible for TRS credit, I
will be required to pay any deposits and fees that are due if I want to have this service or compensation included in the calculation of my
benefits. I also understand that it is the decision of TRS whether my service or compensation is eligible for TRS credit.
Signature of Member
Date