City Statement For Occupational Disability
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1
2City Statement for
TMRS
Occupational Disability
Please type or use only black ink and do not highlight. Any corrections or whiteouts must be initialed.
MEMBER INFORMATION
Member’s Name (first, middle, last)
Social Security Number
–
–
Mailing Address
Daytime Phone Number
(
)
–
City
State
Zip Code
Employing City:
–
A COPY OF THIS COMPLETED FORM MUST BE ATTACHED TO THE MEMBER AND PHYSICIAN
STATEMENTS
JOB DESCRIPTION
Provide a brief statement of job description and job duties and also attach a photocopy of the employee’s job description:
DESCRIPTION OF ACTIVITIES CUSTOMARILY REQUIRED FOR THIS POSITION
Include information regarding the following: how often (never, occasionally, or frequently), and for how long at a time, does
the position require:
Frequency
Duration
Lifting or carrying 1-10 lbs.
Lifting or carrying 11-20 lbs.
Lifting or carrying 21-40 lbs.
Lifting or carrying more than 40 lbs.
Bending or stooping
Reaching above shoulder level
Driving equipment/vehicles
Working with machinery
Climbing ladders, stairs, etc.
Walking
Standing
Sitting
Provide any other required activities that would be applicable in determining whether the member is capable of performing the
customary duties of this position:
CITY OFFICIAL CERTIFICATION
I hereby certify that the information provided above is complete and accurate and that I am duly authorized by the City to complete this form.
X
M M
D D Y Y Y Y
–
–
Signature of City Official
Date Signed
Title
Please read information provided on the reverse side of this document.
Texas Municipal Retirement System
*TMRS40OA*
P.O. Box 149153 Austin, Texas 78714-9153
(512) 476-7577 (800) 924-8677
TMRS-40/OA Revised 12-2001
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