TR-0229 (Rev. 6/12) RDA-413
Waiver of
Refund Waiting
Period for Teachers
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 http://tcrs.tn.gov
This form is to accompany the Member Refund of Accumulated Contributions Application. Authorization for this request
is found in Tennessee Code Annotated, Section 8-37-210(b), amendment effective July 1, 1981. The teacher requesting
the refund should complete Section 2 or Section 3. Section 4 must be completed by the Employer.
SECTION 1. MEMBER INFORMATION
Member ID Last 4 SSN: XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Phone Number
SECTION 2. TEACHER EMPLOYED AND PAID ON A CONTINUOUS TWELVE-MONTH BASIS
Board of Education Effective Date of Employment
I have been employed and paid on a continuous twelve-month basis as a teacher by the above-noted Board of Education
as of the above-noted effective date.
Member’s Signature Date
SECTION 3. REASON FOR TERMINATION
Board of Education Effective Date of Termination
I hereby have voluntarily terminated my position as a teacher with the above-noted Board of Education on the above-
noted effective date. I will no longer be residing in the State of Tennessee and have not been re-employed nor will I
seek employment in the near future with any employer covered by the Tennessee Consolidated Retirement System.
I hereby have been terminated as a teacher due to budgetary problems by the above-noted Board of Education on the
above-noted effective date.
Member’s Signature Date
SECTION 4. EMPLOYER CERTIFICATION
I hereby certify that the above-named person was employed by this school system and has been/or will be terminated for
the reason as documented above.
Board of Education Date of Termination
Employer’s Name and Title
Employer’s Email Phone Number
Employer’s Signature Date
If the teacher does not meet the conditions under Section 2 or Section 3, he/she will not be refunded less than four (4) months
following cessation of service in accordance with Tennessee Code Annotated, Section 8-37-210(b). No refund will be made
to a qualifying teacher until that teacher’s fi nal retirement contribution is received and credited to his/her account.
