TR-0088 (Rev. 6/12) RDA-413
Affi davit of
Forged Check
Endorsement
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 http://tcrs.tn.gov
Please complete this form to notify the Tennessee Consolidated Retirement System (TCRS) of a check
that was forged (i.e., the check was endorsed with your signature and you did not authorize such
endorsement). Please submit two copies of this form to TCRS along with a copy of your driver’s
license. Once submitted, please allow 8-10 weeks for completion of the process.
SECTION 1. MEMBER INFORMATION
Member ID Last 4 SSN: XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Phone Number
I have examined State warrant check number in the amount of $
dated issued to me by the Tennessee Consolidated Retirement System. I fi nd that
I did not endorse the check, nor have I authorized my name thereon, nor have I participated in any
manner in the proceed derived from negotiation of said check. The endorsement of my name on this
check, therefore, is a forgery.
Member’s Signature Date
SECTION 2. NOTARY INFORMATION
STATE OF
COUNTY OF
Sworn to and subscribed before me this ________ day of ___________________, 20________.
(My Commission Expires)
(Notary Public)
(Notary Seal)
