Teachers' Retirement
System (TRS)
Enrollment Form
4101 MacCorkle Avenue, SE
Charleston, WV 25304
304-558-3570 or 800-654-4406
www.wvrerement.com
Consolidated Public Retirement Board
May 2015
Date of Hire
Have you previously contributed to the Teachers Retirement System?
Listpreviousemploymentwithemployerswhoparticipateinthe
Teachers’RetirementSystem
Date
Employment
Began (M/D/Y)
Date
Employment
Ended (M/D/Y)
Didyouwithdrawyour
retirementcontributionsupon
terminationofemployment?
1.
2.
For
Board
ofEducation
use
Only:
PayrollClerk’sName_________________________________
_________________
TRSPlan1(6.0%EE&15.0%ER)(FirstbecameamemberofTRSpriortoJuly1,2015)
TRSPlan3(6.0%EE&7.5%ER)(FirstbecameamemberofTRSpriortoJuly1,2015)
TRSPlan9(6.0%EE&7.5%ER)(HiredforFirsttimeandFirstbecameaTRSmemberonorafterJuly1,2015)
3.
ForCPRBuseonly:
Date
Employer Name
SSN
Telephone Number
Section 1: Employee Information
Full Name
Mailing Address
State Zip Code
City
Date of Birth
Have you previously contributed to the Teachers' Defined Contribution (TDC) Retirement System?
Are you currently a member of or have you retired from the Public Employees Retirement System, Teachers’ Retirement System, State Police Plan B or a Higher Education
Retirement Plan?
Position Status
Type of Rate of Pay
Rate of Pay
Scheduled Hours Per Day Contract Days
Payroll Frequency
Weekly Bi-Weekly
Semi-Monthly
Monthly
Job Position
Teacher Admin
Service Personnel
SPTB
TRS
PERS
If yes, please check the retirement system.
Gend
er
Female
Male
Partime Elected
Regular Temporary
Daily
Hourly
Monthly Yearly
Yes No
Yes No
Yes No
Signature
Section 2: Employer Use Only
Current TDC Member
CPRB Staff name:______________________________________
AppX/Microfilm Checked
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