TR-0033 (Rev. 6/12) RDA-413
Ofﬁ cial Notiﬁ cation
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
Please complete this form to notify the Tennessee Consolidated Retirement System (TCRS) of a
retirement system member who has deceased. If you are the executor of the estate, you are not
required to provide your Social Security number in Section 2.
SECTION 1. DECEASED MEMBER INFORMATION
Member ID Last 4 SSN XXX-XX- Date of Death
SECTION 2. CLAIMANT INFORMATION
SSN Date of Birth
City State Zip Code
Email Phone Number
Relationship to Deceased
SECTION 3. REQUIRED DOCUMENTATION
A photocopy of the deceased member’• s death certiﬁ cate must accompany this form.
If the applicant is the court-appointed executor, the appointment must accompany this form.•
If the current beneﬁ ciary on ﬁ le is deceased, a copy of the beneﬁ ciary’s death certiﬁ cate must •
accompany this form.
Claimant’s Signature Date