Fillable Af davit of Unused Accumulated Sick Leave Tennessee (State of Tennessee)

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Af davit of Unused Accumulated Sick Leave Tennessee (State of Tennessee)

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TR-0416 (Rev. 1012) RDA-413
Page 1 of 2
Affi davit of Unused
Accumulated
Sick Leave
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 http://tcrs.tn.gov
If offi cial sick leave records have been lost or destroyed, the employer may certify unused sick leave days to
the Retirement System for credit pursuant to Tennessee Code Annotated, Section 8-34-604 provided: (1) the
employee provides a sworn affi davit stating as nearly as possible the number of unused sick leave days to the
employee’s credit at the time the employee left the employ of the employer; (2) one current or former co-worker
of the employee supplies a sworn affi davit certifying he/she was familiar with the employee’s attendance record
at issue and to his/her best belief, the number of unused sick leave days contained in the employee’s affi davit
is reasonable; and (3) the employer certifi es the number of unused sick leave days contained in the employee’s
affi davit is reasonable based on the terms of the employer’s sick leave policy in effect during the employee’s
employment with the employer.
Part I of this form must be completed by the employee/claimant. The current or former co-worker as described
above must complete Part II. Parts I and II must be notarized upon signing and the time claimed in Part I must
agree with that certifi ed in Part II. The present department head of that employer under which the sick leave was
accrued must complete Part III. Separate affi davits must be fi led for each employer. Please note that any intentional
misstatement constitutes fraud and will cause forfeiture of all related benefi ts in the Retirement System.
SECTION 1. CLAIMANT INFORMATION
Member ID Last 4 SSN XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Phone Number
SECTION 2. CLAIMANT SICK LEAVE INFORMATION
Name of Employer During Which the Leave was Accrued
Total Number of Unused Sick Leave Days Being Claimed
Number of Sick Leave Days Accrued Annually
9 days
10 days
11 days
12 days
Period of Service for Sick Leave Days Claimed
I, the employee/claimant, hereby apply for sick leave credit as stated above and further certify, to the best of my
knowledge and belief, that the above accurately refl ects, as nearly as possible, the number of unused sick leave
days to my credit at the time I left the employ of the employer listed above.
Applicant’s Signature Date
From
(Example 7/1/60)
To
(Example 6/30/61)
Months in
Full Year of Service
(Example 12)
Months
Worked
(Example 12)
Position Held
TR-0416 (Rev. 1012) RDA-413
Page 2 of 2
SECTION 3. CURRENT OR FORMER CO-WORKER CONFIRMATION
I certify that I am a current or former co-worker of the employee/claimant listed on the front of this form and I
was familiar with the employee’s attendance record with the employer at issue. I further certify, to the best of
my belief, that the number of unused sick leave days contained in the employee’s certifi cation on the front of
this form is reasonable.
Full Name
Mailing Address
City State Zip Code
Co-Worker’s Signature Date
SECTION 4. EMPLOYER CERTIFICATION
I hereby certify that the offi cial sick leave records of the number of unused sick leave days the employee/claimant
had remaining at termination of employment have been lost or destroyed. I further certify that the number of
unused sick leave days contained in the employee’s certifi cation on the front of this form is reasonable based on
the terms of our department’s sick leave policy in effect during the employee’s employment with this department.
I understand that this representation is subject to audit by the Tennessee State Comptroller as provided in
Tennessee Code Annotated, Section 8-34-318.
Employer’s Signature Date
Employer’s Address
Department
Email Phone Number
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Af davit of Unused Accumulated Sick Leave Tennessee (State of Tennessee)

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Completed 27 January 2021

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