Retirement Plan Certification



The University of Texas at El Paso

RETIREMENT PLAN CERTIFICATION

Name:       Last 4 digits of SSN:      

Last First MI

Position:      

► It is important that we ascertain a history, as well as current status, of your retirement plan participation. Please answer the following questions to the best of your knowledge, then sign and date at the bottom of this form.

1. When and where were you first employed in public/higher education in Texas?

Year District/College Location

2. Do you or have you ever participated in the Optional Retirement Program of Texas?

Yes

No

3. Have you every participated in the Teacher Retirement System of Texas?

Yes

No

4. Are you currently contributing to Teacher Retirement System of Texas through other employment, i.e., El Paso Community College, local school district, etc.?

Yes With whom?:      

No

► If the answer to any of the above questions is “Yes”, please complete the following:

Yes No Have you ever worked for any agency of the State of Texas other than in public education?

Yes No Have you withdrawn a Texas Retirement System of Texas account?

|School District, College, or Agency |Location |Year |Under What Name |If Withdrawn, please |

| | | | |give date. |

|      |      |     |      |      |

|      |      |     |      |      |

|      |      |     |      |      |

|      |      |     |      |      |

5. Are you a State of Texas service retiree? Yes Retirement Date:      

No

6. Are you enrolled in another statewide insurance plan? Yes

No

I certify that the statements made by me in this certification are true, complete and correct to the best of my knowledge.

Employee Signature Date

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