Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, TN 37243-0201
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Name (Last) (First) (Middle) (Maiden)
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In accordance with T.C.A. § 8-35-125, any member who is separated from service for reason other than retire-
ment or death may elect to forfeit all contributory and noncontributory service established by such member in
the Tennessee Consolidated Retirement System (TCRS) for the purpose of establishing such service in another
state, federal, county or municipal retirement program provided the following conditions are met:
1. The member must not have received any retirement benefits based upon such service;
2. The service must be creditable in the other retirement program;
3. The member must have taken a refund of his/her accumulated contributions, if any, in
the TCRS; and
4. The member must forfeit all service established in TCRS.
I hereby certify that I have met the above conditions and do hereby forfeit my service in TCRS pursuant to
T.C.A. § 8-35-125. By forfeiting my service, I acknowledge and understand that I cannot reestablish this
service in TCRS so long as I am entitled to retirement credit for such service in the other retirement program. I
further acknowledge and understand that this forfeiture of service shall terminate my membership in the
TCRS and shall constitute a wavier of all my rights in the TCRS on account of the service forfeited.
_________________________________ ____________________________________
Date Signature
State of ________________________
County of ________________________
On this __________________, 20____, before me, a notary in and for said county and state, residing therein,
duly commissioned and sworn, personally appeared _____________________________, personally known to
me to be the person whose name is subscribed to the foregoing, or proved to me on the basis of satisfactory
evidence and acknowledged to me that such person executed the same.
WITNESS my hand and official seal. _____________________________________
My Commission Expires: _____________________________________
TR 0397 RDA 413
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Notary Public
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