TR-0467 RDA-413
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
Retirement System.
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) ________________________________________________________
Notary Public
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
(800) 922-7772
treasury.tn.gov/tcrs
OR
