Elect to Participate in Opt Ret Prgm_TRS Form 28

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. 09-06
NOTICE OF 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
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.
I designate
as my insurance carrier under the program.
Signature of Faculty Member
Date
THE STATE OF TEXAS; COUNTY OF
BEFORE ME, the undersigned authority, on this day personally appeared
known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that this person
executed the same for the purpose therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE THIS
day of
(SEAL)
County, Texas
Notary Public in and for
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
SWORN AND SUBSCRIBED TO BEFORE ME THIS
Notary Public in and for
Title
day of
,
County, Texas
(SEAL)
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.