Fillable Application for Refund of Installment Payments To apply (State of Tennessee)

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Application for Refund of Installment Payments To apply (State of Tennessee)

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TR-0374 (Rev. 6/12) RDA-413
Application for
Refund of
Installment
Payments
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 http://tcrs.tn.gov
To apply for a refund of the payments made under the installment purchase service program,
complete and return this form to the Tennessee Consolidated Retirement System at the above
address.
SECTION 1. MEMBER INFORMATION
Member ID OR Last 4 SSN XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Phone Number
Date of Last Installment Payment
I certify that the above information is complete and correct. I hereby make application to cancel my
contract and return the installment payments I have made toward the service purchase to date. I
understand that upon withdrawal of my installment account, I give up the right to participate in this
program for a period of three (3) years.
Member’s Signature Date
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Application for Refund of Installment Payments To apply (State of Tennessee)

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Completed 27 January 2021

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