Fill - Free fillable APPLICATION FOR DISABILITY RETIREMENT BENEFITS Tennessee Consolidated Retirement (State of Tennessee) PDF form

TR-0388 (Rev. 8/18) RDA-413

Page 1 of 8

Please select one:

q Ordinary Disability Retirement - Member must have ve years of creditable service and suffer a disabling condition

during a period of active employment prior to service retirement eligibility.

q Accidental Disability Retirement (on-the-job accident only) - No minimum service is required. Member must apply

within one year of paid service or within two years of the injury and the disability must be the result of a job-related

accident or injury that occurs without negligence on the part of the member while he is performing his duty.

If a member does not become eligible for benets under Ordinary Disability or Accidental Disability, he/she may be

eligible for Inactive Disability. A determination will be made upon review of submitted medical documentation.

Please refer to pages 7 and 8 for detailed instructions. Do not sign this form until it is notarized (see Section 6).

SECTION 1. MEMBER INFORMATION (Completed by the Applicant.)

Member ID Last 4 SSN XXX-XX- Date of Birth

Full Name

Mailing Address

City State Zip Code

Email Phone Number

Last Employer (Department of Institution Name)

Title of Position Date Employment Terminated

APPLICATION FOR DISABILITY RETIREMENT BENEFITS

Tennessee Consolidated Retirement System

Tennessee Department of Treasury

502 Deaderick Street • Nashville, TN 37243-0201 • 800.922.7772 • RetireReadyTN.gov

TR-0388 (Rev. 8/18) RDA-413

Page 2 of 8

SECTION 2. BENEFICIARY INFORMATION (One beneciary or estate required regardless of plan

selected. If no beneciary is selected, TCRS will assume a beneciary election of Estate

if you choose a single life annuity plan.)

As recipient of the benet plan selected in Section 1, I designate the following beneciary(s):

Beneciary #1

Full Name

Mailing Address

City State Zip Code

Beneciary’s Date of Birth Beneciary’s SSN

Relationship to TCRS Member Gender □ Male □ Female

Beneciary #2

Full Name

Mailing Address

City State Zip Code

Beneciary’s Date of Birth Beneciary’s SSN

Relationship to TCRS Member Gender □ Male □ Female

Beneciary #3

Full Name

Mailing Address

City State Zip Code

Beneciary’s Date of Birth Beneciary’s SSN

Relationship to TCRS Member Gender □ Male □ Female

TR-0388 (Rev. 8/18) RDA-413

Page 3 of 8

SECTION 3. PAYMENT PLAN ELECTION (You may choose the “Single Life Annuity Plan” OR

one

“Survivor Option” payment plan. Selecting more than one payment plan will result in the

application process being delayed.)

SINGLE LIFE ANNUITY PLAN - In the event of your death, any remaining balance of your accumulated

contributions and interest will be paid in a lump sum to the surviving designated beneciary(s).

q Member Only Option - A maximum monthly benefit payable for the member’s lifetime with all benefits ceasing at the

member’s death.

SURVIVOR OPTIONS - TCRS offers four types of Joint and Survivor Plans. The age of the member and the

age of his or her beneciary(s) determine the amount received under each option.

Option I - This option reduces the member’s maximum retirement benet based on the dates of birth of the member

and his or her beneciary(s). In the event the member passes away, the member’s beneciary(s) will receive the same

benet amount as the member for the remainder of the beneciary’s lifetime. If a member has designated more than one

beneciary, the benet will be divided equally between the beneciaries. If any or all beneciaries pass away before the

member, the member’s benet amount will remain the same.

Option II - This option reduces the member’s maximum retirement benet based on the dates of birth of the member

and his or her beneciary(s). In the event the member passes away, the beneciary(s) will receive 50% of the member’s

benet for the remainder of the beneciary’s lifetime. If a member has designated more than one beneciary, the

50% benet amount will be divided equally between the beneciaries. If any or all beneciaries pass away before the

member, the member’s benet amount will remain the same.

Option III - This option reduces the member’s maximum retirement benet based on the dates of birth of the member

and his or her beneciary(s). In the event the member passes away, the beneciary(s) will receive the same benet

amount as the member for the remainder of the beneciary’s lifetime. If a member has designated more than one

beneciary, the benet will be divided equally between the beneciaries. In the event the beneciary passes away

before the member, the member’s benet will increase to the member’s maximum benet under the single life annuity

option. If multiple beneciaries have been designated, a portion of the member’s benet that was designated for a

beneciary that dies before the member will revert to the amount the member would have received under the regular

plan.

Option IV - This option reduces the member’s maximum retirement benet based on the dates of birth of the member

and his or her beneciary(s). In the event the member passes away, the beneciary(s) will receive 50% of the member’s

benet for the remainder of the beneciary’s lifetime. If a member has designated more than one beneciary, the 50%

benet amount will be divided equally between the beneciaries. In the event the beneciary passes away before the

member, the member’s benet will increase to the member’s maximum benet under the single life annuity option. If

multiple beneciaries have been designated, a portion of the member’s benet that was designated for a beneciary

that dies before the member will revert to the amount the member would have received under the regular plan.

TR-0388 (Rev. 8/18) RDA-413

Page 4 of 8

SECTION 4. DIRECT DEPOSIT INFORMATION

Type of Account:

Checking

Savings

Financial Institution

Routing Number Account Number

If you want your benet directly deposited into a checking account, tape a

voided, preprinted check in this box. You may cover the text with the voided

check. If you want your benet deposited into multiple accounts, please

complete the Direct Deposit form located at treasury.tn.gov/tcrs.

PLEASE NOTE: TCRS no longer issues monthly retirement benets by

check. If TCRS has not received your authorization to direct deposit your

benet payment, a debit card will be issued and mailed to your home

address and all future TCRS benet payments will be made by adding your

monthly benet to the debit card balance.

SECTION 5. WITHHOLDING SELECTION (Select one.)

q A. I elect NOT to have income tax withheld from my pension. (

Do not complete lines B or C if you choose

this selection.)

q B. I want the following TOTAL amount withheld from each payment: $________________

I want the following PERCENTAGE withheld from each payment: _________________%

(Do not complete lines A or C if you choose this selection.)

q C. I want my withholding from each payment to be gured using the following ling status and exemptions:

Filing Status:

Single

Married

Married, but withholding at a higher single rate

Total Exemptions Claimed: ____________

In addition to the calculated deduction based on ling status and exemptions, I want the following

additional amount withheld from each pension payment. $_________________.

TR-0388 (Rev. 8/18) RDA-413

Page 5 of 8

SECTION 6. SIGNATURE AND NOTARY (This form must be signed and notarized, then forwarded to

employer for certication.)

Under the penalties of perjury, I attest that as of the date of this application for retirement benets, I am either

a United States citizen or qualied alien as dened in T.C.A. §4-58-101, et seq. I acknowledge and understand

that should I knowingly and willfully make a false, ctitious, or fraudulent statement or representation relative

to my citizenship or immigration status, or conspire to defraud the state by securing a false claim allowed

or paid to another person, I shall be liable under either The Tennessee Medicaid False Claims Act pursuant

to T.C.A.. §71-5-181-§71-5-185 or The False Claims Act pursuant to T.C.A. §4-18-101- §4-18-108 and may

have a criminal action brought against me alleging a violation of 18 U.S.C. §911, which provides that whoever

falsely and willfully represents himself to be a citizen of the United States shall be ned under Title 18 of the

United States Code or imprisoned not more than three (3) years, or both.

I also acknowledge that I have attached documentation proving said citizenship. (Please see Section 1

instructions on pages 7 and 8 for a complete list of acceptable documentation.) Note: Photocopies of the

documents are acceptable and any document submitted will not be returned to you.)

Member’s Signature

______________________________________ Date _______________________

State of Tennessee / County of _____________________

_____________________________________, who personally appeared before me on this, the ______ day of

_______________________, 20______, makes oath that (he)(she) executed the foregoing instrument.

(Notary Seal) _____________________________________________

Notary Public

_____________________________________________

My Commission Expires

TR-0388 (Rev. 8/18) RDA-413

Page 6 of 8

SECTION 7. EMPLOYER CERTIFICATION (This section must be completed by ofcial department

payroll personnel. If member has been out of service for more than 60 days, complete only

Sections F and G below.)

A. MEMBER’S TERMINATION DATE (last paid date of service, annual leave or sick leave):

B. Please list all individual payroll periods that the employee was paid on for his/her remaining months of service

that have not been reported to TCRS at this time. If any salaries are estimated, indicate by marking “(Est)”

and provide any changes or revisions in the actual payroll information as quickly as possible. Any longevity

payments or career ladder payments should be itemized along with any payments made for sick leave,

annual leave, vacation time, bonus pay, etc. Please attach additional pages if necessary.

C. Please indicate the total salary for the current year and the portion of the year the salary represents. If the

current year is a partial year, also include the salary from the previous year.

Current Year Salary: $_______________________ Number of Months Included: ____________

D. The service represented is:

Full-Time

Part-Time (percentage worked) _____________ %

E. The member is paid on:

Fiscal Year (July 1 - June 30)

Academic Year (Sept. 1 - Aug. 31)

Calendar Year (Jan. 1 - Dec. 31)

Other: _______________________

F. If this member worked less than 12 months per year, indicate the total number of days worked this year.

A full year consists of:

180 Days

200 Days

220 Days

Other: __________

G. Please certify the unused sick leave this member had remaining. Do not include days for which member

received a lump-sum payment. (For employees who are Fire and Police, only certify days.)

Days: _______________ Hours: _______________ Hours Worked Per Day: ______________

How many sick days did the employee accrue annually over the last three (3) years?

This Year: _________________ Last Year: _________________ Prior Year: ___________________

Employer’s Signature Date

Employer’s Address

Department

Email Phone Number

Breakdown of Final Salary

Month Payroll Period Type of Payment Amount Employee Contributions Service Credit

TR-0388 (Rev. 8/18) RDA-413

Page 7 of 8

When to File an Application for Disability Retirement

Your application for retirement should be forwarded to TCRS 60 to 90 days prior to your last paid day of service. The last

paid day of service is either your last day of employment or the last day for which you are paid annual and/or sick leave.

Your application cannot be led more than 150 days prior to your last paid day of service. For eligibility requirements and

questions regarding the continuation of insurance, please contact Benets Administration at 800-253-9981. For eligibility

requirements and questions regarding the continuation of insurance, please contact Benets Administration at 800-253-

9981.

Directions for Completing

Regardless of the type of disability selected, you must submit the following items with your application:

; Statement of Disability

; Vocational History

; Medical Records Release Authorization

; Attending Physician’s Report

; Report of Accidental Disability (if applicable)

Forms may be obtained from the TCRS ofce or by visiting treasury.tn.us/tcrs.

Medical and/or psychological documentation of total and permanent disability must accompany your application. This

documentation includes ofce notes and summaries, hospital admission and discharge summaries, and test results. It is

your responsibility to obtain this vital information.

Section 1 - The date employment terminated is the last working day (including all annual and/or sick days) for which you

are paid. The effective date of retirement is the day immediately following the last paid day or the rst day of eligibility for

benets (i.e., 60th birthday). Payment will be made retroactive to your date of retirement not to exceed 150 days prior to

receipt of the application in our ofce.

If you are a United States citizen and are applying for retirement benets from TCRS through the submission of this

application, you must provide one (1) of the following:

• A valid driver’s license or photo identication license issued by the Tennessee Department of Safety or a valid driver’s

license or photo identication license from another state where the issuance requirements are at least as strict as those

in Tennessee, as determined by the Department of Safety;

• An ofcial birth certicate issued by the United States or any of its territories; however, Puerto Rican birth certicates

issued before July 1, 2010 shall not be recognized;

• A United States government-issued certied birth certicate;

• A valid, unexpired United States passport;

• A United States certicate of birth abroad (DS-1350 or FS-545);

• A report of birth abroad of a United States citizen (FS-240);

• A certicate of citizenship (N560 or N561);

• A certicate of naturalization (N550, N570 or N578);

• A United States Citizen identication card (I-197, I-179);

• Any successor document to six items listed above;

• A social security number that the Department may verify with the Social Security Administration

If you are a “qualied alien” and are applying for retirement benets from TCRS through submission of this application,

you must provide two (2) forms of documentation of identity and immigration status as determined by the United States

Department of Homeland Security to be acceptable for verication through the Systematic Alien Verication for Entitlements

(“SAVE”) program. (For the denition of a “qualied alien”, please refer to 8 U.S.C. Section1641.) Common types of

documents used to establish immigration status include, but are not limited to, the following:

• I-327 (Reentry Permit);

TR-0388 (Rev. 8/18) RDA-413

Page 8 of 8

• I-551 (Permanent Resident Card or “Green Card”);

• I-571 (Refugee Travel Document);

• I-766 (Employment Authorization Card);

• Machine Readable Immigrant Visa (with Temporary I-551 language);

• Temporary I-551 stamp (on passport or I-94);

• Unexpired foreign passport;

• WT (visitor for business)/WB (visitor for pleasure) Admission Stamp in unexpired foreign passport;

• I-20 (Certicate of Eligibility for Nonimmigrant F(1) student status – “student visa”);

• DS2019 (Certicate of Eligibility for Exchange Visitor (J-1) Status).

Common types of documents used to establish identity include, but are not limited to, the following:

• Driver’s license;

• Identication card with photograph issued by federal, state or local government agencies or entities;

• School identication card with photograph;

• Voter’s registration card;

• United States military card or draft record;

• Military dependent’s identication card;

• United States Coast Guard Merchant Mariners Document (MMD) Card;

• Native American tribal document;

• Driver’s license issued by a Canadian government authority

Photocopies of the above-referenced documents are acceptable. Documents submitted will not be returned to you.

Section 2 - If you select the Member Only Option Plan, you may designate an individual or your estate as beneciary. If you

select Option I - IV, you must designate an individual as beneciary. Proof of the beneciary’s birth date should be included.

Section 3 - You must select only one benet plan.

Section 4 - Please attach a voided check OR provide your savings account information. As required by state law, TCRS

monthly benets will be deposited directly to the checking or savings account indicated on your retirement application.

Payments will be available on the last working day of each month. You will be notied in writing of any changes made to the

amount of your net benet. All correspondence and year-end statements will be mailed to your home address.

Section 5 - TCRS benets are subject to federal taxation. However, it is your choice whether to have federal income tax

withheld from your TCRS pension. Before completing Section 5, please consult your tax preparer regarding the correct ling

status and number of exemptions for your monthly pension. If you leave this section blank, we will automatically assign a

status of married with three exemptions.

Section 6 - Must be signed before a Notary and notarized to be valid.

Section 7 - Submit your signed application to your employer to complete Section 7. Upon completion, the application should

be returned to the Tennessee Consolidated Retirement System. If you have been out of service for more than 60 days, Items

A-F in Section 7 do not need to be completed. However, in order for you to be properly credited with your unused sick leave,

Item G must be certied by your employer.

Acknowledgement

All applications will be acknowledged by letter after we receive them. If you do not receive an acknowledgment letter within

two weeks, please contact Member Services at 800-770-8277.

If you should return to service on a part-time or full-time basis with an agency covered by the retirement system, you should

notify TCRS to avoid an overpayment of retirement benets.

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