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: |
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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) _________________________ |
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: ____________________________________
