Release of Claim Form Under Section 1310 (code DB28)

RELEASE OF CLAIM FORM
UNDER SECTION 1310
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided.
First Name
MI Last Name Permanent Home Address
Social Security Number (last 4 digits only)
Apt. No. Primary Phone Number (Check one:
(
City State Zip Code
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,
so do not enter a temporary address; instead, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a
“Beneficiary’s Change of Address Form” (code DM14) with TRS.
If you are providing new information above, please indicate the effective date:
PART B: Please print all information below, and sign and date this form.
I, _____________________________________________ state that I am the ______________________of________________________
(relation to deceased)
(name of deceased)
__________________________________, a member of TRS with membership number_ ________________________ . I consent to the
collection by _________________________________________________________ of the sum of $_ ____________________________
due from TRS. I further agree not to hold TRS, the Teachers’ Retirement Board, or any of its members, individually or collectively, liable
at any time for payment of this sum to the above-mentioned individual.
SIGNATURE _________________________________________________________
DB28 (6/10) CONTINUED ON PAGE 2
DATE (M/D/Y)_ _________________________
PAGE 1
CONTINUED FROM PAGE 1
PART C: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an American consul.)
State of _____________________________ )
) s.s.:
County of _ __________________________ )
_On the _____________ day of _________________, __________, before me personally appeared the person known to me
to be_ __________________________________________________________, the individual who executed the foregoing
instrument and acknowledged to me that (s)he executed the same.
Signature:_ _____________________________________________________
Official Title:_____________________________________________________
Expiration Date of Commission:_ ____________________________________
DB28 (6/10)
PAGE 2