TR-0002 (Rev. 6/12) RDA-413
Application for
Retirement Credit
for Educational
Leave of Absence
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
In order to be eligible to establish retirement credit for an educational leave of absence, you must obtain the approval of your
employer and the Board of Trustees of the Tennessee Consolidated Retirement System and you must make the necessary
contributions, if required, to establish such service. You must be reemployed by such employer within one (1) year following
the leave period and remain so employed for a least one (1) year thereafter.
Member ID OR Last 4 SSN XXX-XX- Date of Birth
Full Name Gender Male Female
Mailing Address
City State Zip Code
Email Phone Number
Explain the Nature of the Leave and How it Relates to Your Employment:
Applicant’s Signature Date
SECTION 2. EMPLOYER INFORMATION (to be completed by the employer during the leave of absence)
Name of Agency or Department
Employee’s Position Prior to Leave of Absence
Period of Leave to Annual Salary Prior to Leave $
I hereby certify that the above-mentioned employee has/had approval to take an educational leave of absence for the
purpose of engaging in academic research related to his/her employment and whose leave is intended to increase his/her
ef ciency as an employee and to make monthly contributions, if required, to the retirement system for this leave. If needed,
the employee is to make nancial arrangements with the employer for the monthly contributions.
Department Head’s Signature Date
Budget Directors Signature Date