Trsnyc Form Db28 – Fill Out and Use This PDF

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)

(

)

( )

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) _________________________

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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: ____________________________________

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