Form Rm-0212-1015 - Employer Certification For Disability Retirement printable pdf download

RM-0212-1015

State of New Jersey — Department of the Treasury

Division of Pensions and Benefits • PO Box 295 • Trenton, New Jersey 08625-0295 • (609) 292-7524

EMPLOYER CERTIFICATION FOR DISABILITY RETIREMENT

Retirement System (Check appropriate fund)

PERS

TPAF

PFRS

SPRS

JRS

_________________________________________________

NAME OF EMPLOYEE

NAME OF EMPLOYER

_________________________________________________

TITLE /POSITION (at time of retirement) (Attach job description - PERS only)

EMPLOYER'S ADDRESS

_________________________________________________

EMPLOYER'S ADDRESS (Continued)

SOCIAL SECURITY NUMBER

_________________________________________________

MEMBERSHIP NUMBER

EMPLOYER'S PHONE NUMBER

Date employee's service terminated (Applicant will not render any service to

or earn salaries, wages, fees or other compensation from this agency after this date.)

________________________________________

EMPLOYEE STATUS

Full-Time

Part-Time

Is there an alternate job/position available to the member?

YES

AUTHORIZED LEAVE OF ABSENCE

Paid Sick Leave - Dates from __________________________________________ to ______________________________________

Paid Personal Leave - Dates from ______________________________________ to ______________________________________

Unpaid Sick Leave - Dates from _______________________________________ to ______________________________________

Unpaid Personal Leave - Dates from ___________________________________ to ______________________________________

Temporary Disability Insurance - Dates from _____________________________ to ______________________________________

UNAUTHORIZED LEAVE OF ABSENCE — Dates from______________________ to ______________________________________

7. a)

Is the member currently on suspension?

YES If yes, give date of suspension _______________________

Is suspension

PAID or

UNPAID

b) Is the applicant facing disciplinary action?

YES If yes, attach copies of the preliminary and final notices of

disciplinary action or their equivalents, or any settlement agreement in lieu of disciplinary action.

Is the applicant facing indictment?

YES If yes, attach a copy of the indictment.

Was applicant dismissed?

YES If yes, give reason and date ______________________________________________

TYPE OF DISABILITY RETIREMENT (Select One) —

ORDINARY

ACCIDENTAL (Give dates of accident(s) below)

1) ______________________

2) ________________________

3) ________________________

4) _______________________

Is this an Involuntary Disability Retirement?

YES

If yes, please provide a written statement of grounds for requesting an involuntary retirement.

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Is there any other job/position available to member?

YES If yes, attach a description of the available job/position

10. IF THE EMPLOYEE IS FILING FOR AN ACCIDENTAL DISABILITY RETIREMENT, PLEASE COMPLETE THE SECTION BELOW

a) Did this accident occur during the performance of the employee's duties?

YES

b) Is a record of this accident on file?

YES If yes, attach copy of accident report, including any witness statements.

c) Was this accident a result of the employee's negligence?

YES

d) Has the employee filed a claim for Workers' Compensation?

YES

If yes, dates of periodic payments from __________________ to _________________