TR-0301 (Rev. 6/12) RDA-413
Application for
Retirement Credit
for a Period of
Temporary Disability
under Workers’ Compensation
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
Any TCRS member who receives a temporary disability bene t from the division of Claims Administration
or under a workers’ compensation program shall be entitled to establish retirement credit for this period of
absence from service. To establish this credit the member is required to make a lump sum payment of the
contributions that would normally have been made during the period of absence, plus interest. Employees
of a participating local government may establish credit for periods of temporary disability only if the local
government has passed a resolution authorizing such service.
No member shall be granted retirement credit in excess of one (1) year per occurrence of temporary
Member ID OR Last 4 SSN XXX-XX- Date of Birth
Full Name Gender
Male Female
Mailing Address
City State Zip Code
Email Phone Number
Employer During Temporary Disability
Period of Temporary Disability to
I hereby claim retirement credit for a period of time which I was receiving bene ts from a workers’ compensation
plan during a period of temporary disability.
Applicant’s Signature Date
SECTION 2. EMPLOYER INFORMATION (to be completed by employer during the period of
temporary disability)
Name of Agency or Department
Period of Temporary Disability to
Annual Salary Immediately Prior to Leave
I certify that the above-named employee was receiving bene ts from a workers’ compensation program for the
period of temporary disability noted above.
Department Head’s Signature
Printed Name and Title Date