Trs Nyc Release Of Claim Form printable pdf download

Trs Nyc Release Of Claim Form

RELEASE OF CLAIM FORM

UNDER SECTION 1310

(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)

PART A: All information must be provided.

First Name

MI Last Name

Social Security Number (last 4 digits only)

Permanent Home Address

Apt. No. Primary Phone Number (

Check one:

Home

Work

Mobile)

(

)

City

State Zip Code

Alternate Phone Number

(Check one:

Home

Work

Mobile)

(

)

Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,

so do not enter a temporary address; instead, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded

on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a

“Beneficiary’s Change of Address Form” (code DM14) with TRS.

If you are providing new information above, please indicate the effective date:

PART B: Please print all information below, and sign and date this form.

I, ____________________________________________ state that I am the _____________________of _______________________

(relation to deceased)

(name of deceased)

__________________________________, a member of TRS with membership number ________________________ . I consent to the

collection by ________________________________________________________ of the sum of $ ____________________________

due from TRS. I further agree not to hold TRS, the Teachers’ Retirement Board, or any of its members, individually or collectively, liable

at any time for payment of this sum to the above-mentioned individual.

SIGNATURE ________________________________________________________

DATE (M/D/Y) _________________________

CONTINUED ON PAGE 2

PAGE 1

DB28 (6/10)

Trs Nyc Release Of Claim Form