Fillable Trsnyc Db28 Form in PDF
The TRSNYC DB28 form is a crucial document for individuals navigating the complexities of claiming benefits from the Teachers’ Retirement System of the City of New York (TRS). This form serves as a release of claims under Section 1310, ensuring that the rightful beneficiaries can access funds due to them following the passing of a TRS member. In completing the DB28, it is essential to provide accurate personal information, including the deceased's membership details and the claimant's relationship to the deceased. The form consists of several parts: the first section requires the claimant's personal information, while the second part includes a declaration of consent to collect a specified sum from TRS. Notably, the form also includes a section for notarization, which adds a layer of authenticity and legal validation. Claimants must be diligent in ensuring that their information is up to date and correctly filled out, as any discrepancies could delay the claims process. Understanding the nuances of the DB28 form can significantly ease the burden during a challenging time, allowing beneficiaries to focus on what truly matters.
Preview - Trsnyc Db28 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 |
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MI Last Name |
Social Security Number (last 4 digits only) |
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Permanent Home Address |
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Apt. No. |
Primary Phone Number (Check one: Home Work Mobile) |
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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
SIGNATURE ________________________________________________________ |
DATE (M/D/Y) _________________________ |
DB28 (6/10) |
CONTINUED ON PAGE 2 |
PAGE 1 |
CONTINUED FROM PAGE 1
PART C: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an American consul.)
State of ____________________________ )
)s.s.:
County of __________________________ )
On the _____________ day of _________________, __________, before me personally appeared the person known to me
to be __________________________________________________________ , the individual who executed the foregoing
instrument and acknowledged to me that (s)he executed the same.
Signature: _____________________________________________________
Official Title: ____________________________________________________
Expiration Date of Commission: ____________________________________
DB28 (6/10) |
PAGE 2 |
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Form Characteristics
| Fact Name | Description |
|---|---|
| Purpose | The TRSNYC DB28 form is used to release claims under Section 1310 of the New York State Retirement and Social Security Law. |
| Information Required | Applicants must provide personal details, including name, Social Security number, address, and phone numbers. |
| Notary Requirement | A notary public must complete Part C, verifying the identity of the individual signing the form. |
| Effective Date | Any changes to personal information should include an effective date to ensure accurate record-keeping. |
| Liability Waiver | By signing the form, the individual agrees not to hold TRS or its members liable for the payment of the sum released. |
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