Qualified Domestic Relations Order - Tennessee Consolidated Retirement System Page 4

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CERTIFICATION OF SERVICE
I, ______________________________________, Clerk of the above Court, do hereby certify that an attested copy of the
foregoing has been served by mailing same to the following on this __________ day of _________________________,
20_____:
Name: ________________________________________________
Name: ________________________________________________
Address: _____________________________________________
Address: _____________________________________________
City, State, Zip: ______________________________________
City, State, Zip: ______________________________________
________________________________________________________
(Clerk’s Certi ication Seal)
Clerk’s Signature
TR-0466
Page 4
RDA-413

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