MEMBERSHIP FORM - Tennessee Department of Treasury

RESET FORM
TENNESSEE CONSOLIDATED RETIREMENT SYSTEM
MEMBERSHIP
FORM
502 Deaderick Street
Nashville, TN 37243-0201
(615) 741-4868
Type or print legibly in BLACK ink. The payroll/personnel officer must complete the shaded areas. Not to be used as a Change of Beneficiary Form.
New Member
Transfer from Another TCRS Agency
Member Information
Social Security Number
Birth Date
Last Name
First Name
Sex
Address
City
State
Home Telephone
Work Telephone
Membership Date
Zip
Department Code
Employment (check one)
Full Time
Status
Seasonal
Regular
If teacher, total months worked per year
Retirement Type
Part Time
Employment Date
Temporary
10
Date first deduction will be made
Interim
12
Emergency ______ hours per day ______ days per week
Title of Position
Payroll Officer
Telephone #
Previous Employment—Fill out this section if you have ever been a member of any state or local retirement system.
Name of retirement system(s) other than TCRS:
Name(s) under which you were listed:
Have you ever been refunded your contributions with the TCRS?
Have you ever received benefits from TCRS?
Beneficiary Designation
Last Name
First Name
Name of Institution or Estate
Relationship
Sex
Birth Date
Taxpayer I.D.
Signature of Member
Social Security No.
Address
Date
The laws governing TCRS provide that you may designate more than one person as your beneficiary. For TCRS purposes, the term "person" means any individual, firm,
organization, partnership, association, corporation, estate, or trust. ESTATES, MULTIPLE BENEFICIARIES, AND INSTITUTIONS ARE ELIGIBLE FOR LUMP-SUM
DISTRIBUTIONS ONLY. IF YOU LIST TWO OR MORE PERSONS, YOU HAVE NAMED MULTIPLE BENEFICIARIES AND THEY MAY SHARE EQUALLY IN ANY LUMPSUM PAYMENT. IF YOU HAVE NEVER MADE CONTRIBUTIONS TO TCRS, NO LUMP-SUM PAYMENT WILL BE MADE AND YOUR SPOUSE MAY BE THE ONLY
PERSON ELIGIBLE FOR ANY TYPE DEATH BENEFIT. Certain types of death benefits are payable only to a surviving spouse, provided such spouse is the only person
named as beneficiary. If you name your spouse as beneficiary, he or she may be entitled to monthly benefits should you die in service. (Secondary or contingent
beneficiaries are not permitted.) Contact the TCRS office if you have any questions. If available, I elect Option 1 for my beneficiary in the event of my death. I, the member,
revoke any previous beneficiary nominations and direct that the above designation supersede any previously filed; provided, however, in the event I named my spouse
and another person or persons as beneficiary herein and no death benefit is payable as a result thereof, I direct TCRS to revoke such designation and substitute my spouse
instead as sole beneficiary.
STATE OF ____________________, COUNTY OF ____________________
_____________________________________ personally appeared before me on this the _______ day____________________, 20______,
who makes oath that (he) (she) executed the foregoing instrument.
_________________________________________
My Commission Expires: __________________________
Notary Signature and Seal
After completing form, make two copies. Original—TCRS; Copy—Agency; Copy—Employee
TR–0353 (Rev. 10/05)
RDA 413