Baptismal Record Aidavit
MEMBER INFORMA
TION
Please type or use only black ink and do not highlight. Any corrections must be initialed.
Member’s Name (first, middle, last) Social Security Number
Mailing Address Daytime Phone Number
City State Zip City Name (required)
TMRS Identification Number (not required) City Number
PURPOSE
The purpose of this Baptismal Record Adavit is to certify that a photocopy of a baptismal record is a true copy of said
baptismal record which certifies the date of birth for any given person named in plan records. Completion of this form is
required only if a Baptismal Record is submitted as proof of birth.
I,
(Aant’s name as indicated on TMRS record)
, hereby certify and do solemnly swear that the following are true:
■
that the attached photocopy is a true copy of the Baptismal Record;
■
that the original Baptismal Record is in the possession of
Name of Church
■
located in
Name of City
,
Name of State
■
that there are no alterations on the entry of the name or date of birth on the Baptismal Record;
■
that l am
Aant’s name as indicated on Baptismal Record
; and,
■
that my true and correct date of birth is
Date of birth as indicated on Baptismal Record
.
Aant’s Signature Date Signed (MM/DD/YYYY)
NOTARIZATION REQUIRED
The State of Texas
County of
,
Before me on this day personally appeared
known to me to be the person who signed the above Baptismal Record Ai
davit and declared to me upon
oath that the statement therein contained are true and correct. Given under my hand and seal of oce
this day of , 20 .
(SEAL)
Notary Public, State of Texas
NOTICE TO PERSONS SIGNING THIS AFFIDAVIT
Section 851.101 of the Texas Government Code provides for punishment by fine and/or imprisonment of (i) a person who knowingly makes a false statement in a report or
application to the retirement system in an attempt to defraud the system or (ii) a person who knowingly makes a false certificate of an ocial report to the retirement system.
TMRS • P.O. Box 149153 • Austin, Texas 78714-9153 • 800.924.8677 • 512.476.7577 • FAX 512.476.5576 • www..com *TMRS0052*
TMRS - 0052 • Revised 7-2009
