Kentucky Teachers' Retirement System Military Service Certification And Affidavit

KENTUCKY TEACHERS' RETIREMENT SYSTEM

MILITARY SERVICE CERTIFICATION

AND AFFIDAVIT – QDRO

The Kentucky Teachers' Retirement System member shall complete this form and have it

notarized. The member shall return the notarized form within thirty (30) days of the receipt of this

notice to the address listed below regardless of military service status. Failure to do so will result in

the court being notified of the member's non-compliance with KRS 161.700 and 102 KAR 1:____.

KTRS Member Name: ______________________________________________________________

KTRS Member Number: _____________

Social Security Number:

__________________

Address:

__________________________________________________________________

City:

_____________________

State: __________

Zip:

__________________

Date of Birth:

_______________________

Military Service:

Check the appropriate response:

____

I did NOT serve any active military service.

____

I did serve active military service.

Please send a copy of your discharge papers and provide the dates below:

Period(s) of active military service

From (MM/DD/YY)

To (MM/DD/YY)

________________________

__________________________

b. Check the response which best describes your situation:

____

I am not receiving, nor eligible to receive, any federal retirement benefit based on my

active military service other than Social Security benefits, disability benefits, or non-

regular (reserve) military retired pay under Title 10, US Code, Sec. 1331 to 1337.

____

I am eligible to, but I hereby certify that I will not, use my active military service for any

federal retirement benefit other than Social Security benefits, disability benefits, or non-

regular (reserve) military retired pay under Title 10, US Code, Sec. 1331 to 1337.

____

I am receiving or will receive a federal retirement benefit based on my active military

service other than Social Security benefits, disability benefits, or non-regular (reserve)

military retired pay under Title 10, US Code, Sec. 1331 to 1337. (Enter name and

address of federal retirement system below.)

_____________________________

________________________________________________

Name of Federal Retirement System

Address

I hereby certify that, to the best of my knowledge and belief, the above information is true and accurate.

__________

________________________________________

____________________________

Date

Signature

Telephone Number

Subscribed and sworn to before me this ____ day of ________________ 20__.

Notary Public: ______________________________

County of ___________________________

Commonwealth of Kentucky

My Commission Expires: ______________________

Kentucky Teachers' Retirement System/ 479 Versailles Road / Frankfort, KY 40601/ Toll Free 800-618-1687

Telephone: 502/848-8500

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Kentucky Teachers' Retirement System Military Service Certification And Affidavit - Qdro

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