Election To Transfer Funds From Tcrs To The Optional Retirement Program Form

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ELECTION TO TRANSFER FUNDS FROM TCRS TO
THE OPTIONAL RETIREMENT PROGRAM
BY ELIGIBLE EMPLOYEES OF COLLEGES AND UNIVERSITIES
OF THE STATE OF TENNESSEE
Tennessee Consolidated Retirement System
502 Deaderick Street, Nashville, Tennessee 37243-0201
MEMBER INFORMATION
Name_______________________________________________________________________________________________
Last
First
Middle or Maiden
Social Security Number
____________________________
Date of Birth ________________________
Month
Day
Year
Street
___________________________________
City________________________
State________
Zip ____________
Employer __________________________________________________
Work Phone ______________________________
Institution
ALLOCATION INSTRUCTIONS
Funds transferred to the Optional Retirement Program under this election are to be distributed as follows:
ING-Aetna Life Insurance and Annuity Company
___________
%
TIAA-CREF
___________
%
Variable Annuity Life Insurance Company (VALIC)
___________
%
Total
100
%
CERTIFICATION
— To be signed by member and witnessed by a notary public
I have completed an ELECTION TO TRANSFER MEMBERSHIP FROM TCRS TO THE OPTIONAL RETIREMENT
PROGRAM and hereby also make application for the transfer of my accumulated contributions on deposit with the
Tennessee Consolidated Retirement System to the Optional Retirement Program as authorized by Tennessee Code
Annotated, Section 8-35-409.
I understand that this transfer is considered a total withdrawal of accumulated contributions and service credit and
shall terminate my membership in the Tennessee Consolidated Retirement System in accordance with the provisions
of Tennessee Code Annotated, Section 8-35-104. I further understand that this action constitutes a waiver of all rights
in the retirement system and that contributions so transferred may not be redeposited with the Tennessee Consoli-
dated Retirement System.
I am aware that if I have attained vested rights in TCRS and DO NOT transfer my contributions, I will be entitled to
elect to receive a monthly benefit from TCRS at retirement age based on my service and salary through the date of my
transfer of membership to the Optional Retirement Program. By transferring my contributions, I am forfeiting all
rights to such benefit.
I take this action with full knowledge and understanding of the foregoing and certify that this election is being
made at least thirty (30) days prior to the effective date.
________________________________________
_________________
Signature of Member
Date
STATE OF TENNESSEE, COUNTY OF _________________________________
Personally appeared before me on this ______ day of _______________________,
__________
the within named
_________________________________________, and makes oath that (he) (she) executed the foregoing instrument.
________________________________________
Notary Public Signature
SEAL
My Commission Expires _____________________________
TR-0274 (Rev 5/92)
RDA #413

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