Form Rm-0212-1015 - Employer Certification For Disability Retirement Page 2
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1
2RM-0212-1015
EMPLOYER CERTIFICATION FOR DISABILITY RETIREMENT
11. Base salary subject to pension fund contributions paid for the last full year of service ending on the date of termination (line 3
above); please list number of months at a particular salary and show a total of 12 months for a 12-month employee or 10 months
for a 10-month employee.
TOTAL
# __________months @ $ _______________ from __________________ to ____________________ $ ___________________
# __________months @ $ _______________ from __________________ to ____________________ $ ___________________
# __________months @ $ _______________ from __________________ to ____________________ $ ___________________
# __________months @ $ _______________ from __________________ to ____________________ $ ___________________
TOTAL BASE SALARY PAID FOR LAST YEAR OF SERVICE $ ___________________
12. Has member received a significant annual salary increase in the last 3 years of employment?
NO
YES If yes, please
provide a detailed explanation with documentation such as salary guides and employment contracts and ruling body minutes.
YES If yes, please de-
13. Has there been any retroactive salary paid to the employee within the past three years?
NO
scribe below:
AMOUNT OF
DATE OF
PENSION
NEW ANNUAL
COVERING THE DATES (FROM - TO)
PAYMENT
PAYMENT
DEDUCTION
BASE
$
TO
$
$
$
TO
$
$
$
TO
$
$
14. The following deductions have been made or will be made from the member's base salary during the final two quarterly periods in-
cluding the quarter in which service terminated (see QUARTERLY REPORT OF CONTRIBUTIONS).
State biweekly reporting agencies should attach a screen print of TREADHOC biweekly certification with salaries pro-
jected until termination date in lieu of Item 13.
BACK DEDUCTIONS
BASE SALARY
ARREARS
TOTAL
QUARTER
SUBJECT TO
PENSION
LOAN
NO.
AND/OR
PENSION
ENDING
CONTRIBUTIONS
CONTRIBUTION
REPAYMENT
PAY-
PURCHASES
DEDUCTIONS
THIS QUARTER
MENTS
AMOUNT
$
$
$
$
$
$
$
$
$
$
$
$
✔ CHECKLIST — The following items must accompany this form:
______________ 1. Current Job Description (If question #9 is answered YES, include description of any
other available jobs.)
______________ 2. Copies of indictments, convictions, and/or preliminary and final notices of disciplinary
action. (If Question #7 is answered yes.)
______________ 3. Copies of accident reports, incident reports, witness statements, medical records
relating to the incident, and other related documents.
______________ 4. Copies of Workers' Compensation awards.
Name of Certifying Officer _______________________________________________
Phone Number (_____) _______________
By signing this statement I am certifying, under penalty of perjury, to the truthfulness of the
information contained herein.
Certifying Officer Signature ______________________________________________________
Date _______________________
NOTE: If a member of the retirement system qualifies for periodic benefits payable under the Workers' Compensation law during
the course of active employment, regular pension contributions must be paid to the system by the employer. The payments are
computed on the base salary paid immediately prior to the receipt of Workers' Compensation benefits. These payments are credited
to the member's account in the system and will be treated as employee contributions for all benefit or claim purposes.
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