Certication and Information Release
Authorization
The completion of this form certies that you are the member/retiree/beneciary in question and authorize
TRS to release your information to the person, entity or employer listed below. A copy of a valid photo
identication with a signature (i.e. driver's license or identication card issued by one of the United
States, a U.S. passport, U.S. military identication card, etc.) must be submitted with this signed form.
Certication
The undersigned certify the following:
♦ I am a member/retiree/beneciary of the Teachers Retirement System of Georgia (TRS).
♦ In accordance with the TRS Condentiality Policy, information regarding my TRS account can
not be released to a third party without my written authorization and signature. Further proof of
identication may be required.
♦ If there is a power of attorney or guardian handling my aairs, the proper legal documentation must
be provided to TRS to keep in its records. Furthermore, the power of attorney or guardian must
authorize, in writing, with a signature that he or she consents to the release of the condential
information of the member/retiree/beneciary.
Your Name
Person, Employer or Entity
Name of Member/Retiree/Beneciary
___________________ ______________
TRS Employee Initials Date Veried
TR-30 (04/17)
Two Northside 75 Suite 100 Atlanta, GA 30318 (404) 352-6500 (800) 352-0650 fax (404) 352-4885 www.trsga.com
Use black ink only and please print clearly.
Authorization to Release Information
To Whom it May Concern:
♦ I am a member/retiree/beneciary of the Teachers Retirement System of Georgia (TRS) or I hold a
power of attorney or guardianship for a member/retiree/beneciary of TRS.
♦ I authorize TRS to release information concerning my TRS account to the third party listed below.
For details about the TRS Condentiality Policy, please visit the TRS website (www.trsga.com).
♦ TRS may address this authorization to any party listed below.
To Be Completed by Member/Retiree/Beneciary/Power of Attorney/Guardian
Member/Retiree/Beneciary Social Security Number
I, ___________________________________ hereby authorize the Teachers Retirement System of Georgia
to release information regarding the TRS account of _____________________________________________
to _____________________________________________________________________________________.
________________________________________ _____________________________________
Member/Retiree/Beneciary Signature Power of Attorney/Guardian Signature
__________________________________ ______________________________________
Today's Date Authorization Good Through Date (up to one year)
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