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 *+22W* TRS 22W Rev. 08-11 VERIFICATION OF WORKER'S COMPENSATION PAYMENTS 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 current school official of the Texas public educational institution that paid the salary being verified. 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: You must include all information requested in all columns below. Use one form for each school year in which the member received worker's compensation. Do not verify worker's compensation payments for any month(s) in which the member was not also paid some salary by your public school. Return this form to the member after completion. Do not return this form to TRS. School year Month September October November December January February March April May June July August Amount of salary actually Salary member would have Amount of worker's paid and reported to received each month had compensation paid to TRS each month the injury not occurred member each month Daily rate of pay: 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 was paid the salary shown on this form by this reporting entity and was paid the worker's compensation payments listed on this form and show that all information provided on this form 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 on this form to TRS upon request as required under 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 Notarization of School Official Signature: Date Signed ( ) Telephone Number 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. (SEAL) GIVEN under my hand and official seal this the day of , Month Signature of Notary Public Year Reverse of Form TRS 22W Rev. 08-11 INSTRUCTIONS FOR MEMBER: Worker's compensation payments may be considered to determine creditable service and/or creditable compensation. Take this form to the Texas public school where you rendered service and received worker's compensation payments for completion and certification by a 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 creditable service and/or creditable compensation is indicated. 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 worker's compensation paid prior to September 1, 2011 must be verified no later than September 1, 2016. Beginning with the 2011-12 school year, worker's compensation must be verified no later than five years after the end of the school year in which the payments were received by the member. Worker's 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 workers 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 Retirement Option Plan (DROP). The cost to purchase credit for worker's compensation received prior to September 1, 2011 will increase to the actuarial 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 worker's 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 approves creditable service and/or compensation based on worker's compensation payments that I have received, 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 INSTRUCTIONS FOR SCHOOL OFFICIAL: All information on the front side of this form must be completed, including the "Certification of School Official." This form must be completed and signed by the current TRS reporting official of the Texas public school where the member's service was rendered and the worker's compensation payments were made, 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. This form is to be used only to verify worker's compensation payments. By completing this form and signing the "Certification of School Official," you agree to produce the records used to complete this form upon demand of the retirement system. Verification must be made on records created at or near the time of service. An affidavit based on memory is not sufficient. RETURN THIS COMPLETED FORM TO THE MEMBER. DO NOT RETURN THIS FORM TO TRS.
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