Verification Of Worker`s Comp Payments_TRS Form 22W

1000 Red River Street, Austin, Texas 78701-2698
Telephone (512) 542-6400 or 1-800-223-8778
Rev. 08-11
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
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
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
Signature of Notary Public
Reverse of Form
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
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.