Fillable Application for Retirement Credit for Service Rendered Out-of-State (State of Tennessee)

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Application for Retirement Credit for Service Rendered Out-of-State (State of Tennessee)

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TR-0267 (Rev. 06/12) RDA-413
Page 1 of 3
Application for
Retirement Credit
for Service Rendered
Out-of-State
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 out-of-state
employer. Section 3 is to be completed by the out-of-state retirement system.
SECTION 1. APPLICANT INFORMATION
Member ID OR
Last 4 SSN XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Home Phone
Position Held During Time of Service Being Claimed in Other State
Dates of Service Being Claimed through
Are you presently a member of the Tennessee Consolidated Retirement System?
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.
Applicant’s Signature Date
Before proceeding, please review the publication, “Should I Consider Purchasing Out-of-State
Service”, on the TCRS website to confi rm out-of-state service will benefi t your retirement. If you
have any questions about how out-of-state service is credited toward TCRS retirement, please
contact our offi ce.
TR-0267 (Rev. 06/12) RDA-413
Page 2 of 3
SECTION 2. CERTIFICATION OF SERVICE (to be completed by the out-of-state employer)
The employer is to complete the service and salary information for the above-named employee. This information
should only be taken from offi
cial payroll records.
Enter the service and salary information of the applicant by fi scal year only (July 1 through June 30). Do not list
more than one year of service on a single line. Complete columns A-G with the following information:
SALARY AND SERVICE INFORMATION
(A)
Name of
Employer and
School System
or Department
(B)
Period Served
(C)
Months and
Days Served
(D)
Months
in Year
(E)
Salary
(F)
Status
(G)
If Part-
Time, %
of Time
Worked
From
mm/dd/yy
To
mm/dd/yy
Actual
Months
Actual
Days
Part
Time
Full
time
Ex. Bonn County Schools 07/01/62 06/30/63 12 0 12 $5,000 X
1
2
3
4
5
6
7
8
9
10
The information provided is correct to the best of my knowledge. I understand that the documents used in
certifying this information are subject to audit by the State Comptroller’s offi ce. This information was taken from
the offi cial records of:
Name of Department or Institution Phone Number
Mailing Address
City State Zip Code
Department Head’s Signature
Printed Name and Title Date
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
TR-0267 (Rev. 06/12) RDA-413
Page 3 of 3
SECTION 3. CERTIFICATION OF SERVICE (to be completed by the out-of-state retirement system)
The above-named individual is seeking to establish credit in the Tennessee Consolidated Retirement System for
previous service as a full-time state employee or teacher for a state outside the state of
Tennessee. In order to
establish this service, the law provides that the member may not be receiving or be eligible to receive credit in
any other state for the service being claimed.
Please check your records for the status of the service listed in Sections 1 and 2 and certify the following
statements:
Was the individual named in Section 1 a member of your retirement system?
Yes No
Is the individual named in Section 1 receiving or entitled to receive, at any time in the future, a benefi t from your
retirement system based on the service certifi ed in Section 2?
Yes No
Comments:
Name of Retirement System Phone Number
Mailing Address
City State Zip Code
Retirement System Offi cial’s Signature
Printed Name and Title Date
Please return this completed form to: Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
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Application for Retirement Credit for Service Rendered Out-of-State (State of Tennessee)

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Completed 27 January 2021

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