Fillable Declaration of Disability Tennessee Consolidated Retirement System 502 (State of Tennessee)

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Declaration of Disability Tennessee Consolidated Retirement System 502 (State of Tennessee)

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TR-0027 (Rev. 11/19) RDA-413
Page 1 of 2
Declaration
of Disability
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 w treasury.tn.gov/tcrs
This form is required to be completed and must accompany your request for disability retirement.
SECTION 1. MEMBER INFORMATION
Member ID Last 4 SSN XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Phone Number
Name of Employer Title of Position
SECTION 2. STATEMENT OF MEMBER
In the space provided below, please state in detail the nature of your disability and the reason why you believe
that you are incapacitated from further service. If additional space is needed, please see page 2.
TR-0027 (Rev. 11/19) RDA-413
Page 2 of 2
SECTION 2. CONTINUED...
State in detail the nature of your disability and the reason why you believe that you are incapacitated from
further service.
SECTION 3. SOCIAL SECURITY
Have you applied to the Social Security Administration for disability benets? q Yes q No
If approved, please attach a copy of the letter which states your approval for benets and date of disability.
SECTION 4. WORKER’S COMPENSATION
Do you have or have you had a worker’s compensation claim? q Yes q No
If settled, please attach a copy of the settlement agreement.
Member’s Signature Date
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Declaration of Disability Tennessee Consolidated Retirement System 502 (State of Tennessee)

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Completed 27 January 2021

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