TR-0129 (Rev. 06/12) RDA-413
Page 1 of 2
Application for
Additional
Retirement Credit
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 http://tcrs.tn.gov
For faster processing, you may complete this application through TCRS Member Self-Service at mytcrs.com.
Section 1 is to be completed by the applicant. Section 2 is to be completed by the employer.
SECTION 1. MEMBER INFORMATION
Member ID OR Last 4 SSN XXX-XX-
Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Home Phone
Present Employer Work Phone
Employer During Time of Service Being Claimed
Position Held During Time of Service Being Claimed
Dates of Service Being Claimed through
Are you presently a member of the Tennessee Consolidated Retirement System? Yes No
Have you ever been refunded your account balance from TCRS? Yes No
Is the service being claimed established with any other pension or retirement plan?
Yes No
If yes, please provide the name of that retirement system.
Member’s Signature Date
SECTION 2. CERTIFICATION OF SERVICE (to be completed by employer)
The amount of service credited to a TCRS member’s account will have an effect on retirement benefi ts. It is
important that the service certi
fi ed below is complete and correct.
Position in Which Service was Rendered
Why Was the Service Not Reported Initially?
Employee Elected Not to Join TCRS (see Employer Manual Exhibit III)
Employer Reporting Error or Oversight
Employee Was Not Eligible When the Service Was Rendered
Part-Time Service Independent Contractor Employee of Another Entity
Probationary/Waiting Period Adjunct Faculty Member Substitute Teacher/# Days Taught
Graduate Assistant Student Worker Other ______________________
Other __________________________________________
