TEACHER RETIREMENT SYSTEM OF TEXAS 1000 Red River Street, Austin, Texas 78701-2698 Telephone (512) 542-6400 or 1-800-223-TRST (8778) *+28* TRS 28 Rev. 04-09 ELECTION TO PARTICIPATE IN OPTIONAL RETIREMENT PROGRAM PLEASE PRINT Federal Tax or Social Security No. Name Address Street Address or Box Number Institution City State Name Zip Code City Have you ever elected the Optional Retirement Program in lieu of TRS? Yes If yes, institution name No dates of employment If yes, did you vest under the Optional Retirement Program? Yes No ELECTION OF FACULTY MEMBER Effective , I elect to participate in the Optional Retirement Program (ORP) established under Chapter 830, Texas Government Code, in lieu of membership in the Teacher Retirement System of Texas (TRS). I understand that by this election I will not be eligible for membership in TRS unless I cease to be employed by an institution of higher education and become employed by the Texas public school system other than in an institution of higher education. I further understand that by electing the ORP, I forfeit all accrued rights to benefits from TRS, if any. I am entitled only to a refund of my TRS contribution, if any, and applicable interest. Submission of this form does not constitute a request for refund of my TRS contributions, if any. I understand this election is irrevocable. Signature of Faculty Member Date THE STATE OF TEXAS; COUNTY OF (date), On appears above) acknowledged this document before me a notary public. (printed name of person whose signature (SEAL) Signature of Notary Public AFFIDAVIT OF GOVERNING BOARD OFFICIAL This is to certify that Name of faculty member is a faculty member of Name of institution of higher education is employed on a full-time basis; is eligible to participate in the Optional Retirement Program; and (is) (is not) a member of the Teacher Retirement System of Texas. I hereby certify that the faculty member became eligible to exercise the option to participate in the Optional Retirement Program on the day of , and elected to participate in the Optional Retirement Program on the day of . Signature of Governing Board Official Title NOTE: If this person is a member of the Teacher Retirement System, please send this form and form TRS 29 with the report for the last month in which the faculty member is being reported to the Teacher Retirement System.
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