VERIFICATION OF SOCIAL SECURITY NUMBER
FOR A QUALIFIED DOMESTIC RELATIONS ORDER (QDRO)
Member’s Name: ____________________________________________________________________________________________________
Member’s Social Security or Federal Tax Identiication Number: _______________________________________________
Before me, the undersigned authority, appeared ___________________________________________________________, who,
being by me duly sworn, deposed as follows:
My full name is _______________________________________________________ . My Social Security or Federal Tax
Identiication number is _________________________________ . I am over the age of 18 and I am a resident of
the state of __________________________ . I have personal knowledge of the matters stated in this afidavit.
I am a member of the Tennessee I am the spouse or former spouse of a
Consolidated Retirement System. member of the Tennessee Consolidated
Under penalty of perjury, I swear that the information provided herein is true and I understand
that the information provided by me herein will be used by the Tennessee Consolidated Retirement
System to pay beneits owed to me, if and when they become payable.
Signature of Afϔiant Date
STATE OF ____________________________________
COUNTY OF _________________________________
Before me, personally appeared __________________________________________________________, known or proved to
me to be the person who signed the above afidavit and declared to me, upon oath, that the foregoing
afidavit is true and correct, on this __________ day of _________________________, 20_____.
(Notary’s Seal) ________________________________________________________
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201