ELECTION TO TRANSFER MEMBERSHIP FROM TCRS
TO THE OPTIONAL RETIREMENT PROGRAM
BY ELIGIBLE EMPLOYEES OF COLLEGES AND UNIVERSITIES
OF THE STATE OF TENNESSEE
Tennessee Consolidated Retirement System
502 Deaderick Street, Nashville, TN 37243-0201
I. TO BE COMPLETED BY EMPLOYEE AND WITNESSED BY A NOTARY — Please print or type
Name_______________________________________________________________________________________________
Last First Middle or Maiden
Social Security Number ________________ ___________ Date of Birth ________________________
Month Day Year
Street ___________________________________City________________________ State_________ Zip ____________
Employer ___________________________________________________________________________________________
Institution
I hereby elect to transfer my membership from the Tennessee Consolidated Retirement System to the Optional Retirement Program
(ORP). This election is made with the understanding that I must participate in one of these retirement plans and that I cannot change
this election at a future date. Any period of service for which contributions are made to the ORP will not be treated as creditable
service in the Tennessee Consolidated Retirement System.
I am attaching an ELECTION TO TRANSFER FUNDS FROM TCRS TO THE OPTIONAL RETIREMENT PROGRAM.
I am NOT attaching an ELECTION TO TRANSFER FUNDS FROM TCRS TO THE OPTIONAL RETIREMENT
PROGRAM; therefore, my unused accumulated sick leave is to be certified below.*
_________________________________________ __________________
Signature of Member Date
NOTARIZATION
STATE OF ____________________, COUNTY OF ____________________
Sworn and subscribed before me this the __________ day of __________________________, __________.
______________________________________________ My Commission Expires__________________________
Notary Public Signature
SEAL
II. TO BE COMPLETED BY TECHNICAL SCHOOL, COLLEGE, OR UNIVERSITY
A. Certification of Eligibility for ORP
This is to certify that _____________________________________________ is classified as EXEMPT from the Fair Labor Standards
Act and is NOT a student or temporary employee; therefore, this employee has the option to participate in either the ORP or the TCRS
in accordance with the provisions of Tennessee Code Annotated, Section 8-35-403. This individual is employed:
o Full Time o Part Time
B. Certification of Unused Sick Leave (to be completed only if employee is NOT transferring funds from TCRS)*
Effective _____________________________, this employee has the following unused accumulated sick leave:
Number of hours: _______________ or number of days: ___________________
For teachers: How many sick days did this employee accumulate on an annual basis? o 9 o 10 o 11 o 12
C. Signature of Institution's Designated Certifying Official
_____________ ______________________________________________ _________________________________
Date Signature of Designated Certifying Official Title
TR-0275 (Rev 2/97) RDA #413
