Form C4 - Application For Normal Retirement - 2011
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C4
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016
(602)255-5575 FAX (602)296-2369
Page 1 of 2
APPLICATION FOR NORMAL RETIREMENT
DATE: _______/_______/_______
TO: LOCAL RETIREMENT BOARD
I, ________________________________________, hereby submit my application for retirement under the terms of the
Arizona Corrections Officer Retirement Plan. I meet the minimum eligibility requirements for a normal retirement at time of
termination; namely, (1) 20 or more years of service, (2) age 62 with 10 or more years of service, (3) a dispatcher with 25 years
of service, or (4) the sum of my age and years of credited service equals at least 80 (A.R.S. Section 38-885.(B). I am retiring
on _______/_______/_______, acknowledging that the effective date of my retirement will be the first day of the month
following the date of retirement, with payments beginning on or about the last day of that month (A.R.S. Section 38-890). If
application is being made under a prior law, please state prior system law: ________________________________
ADDRESS: ____________________________________
HOME PHONE NUMBER: (______) _______-__________
______________________________________________
WORK PHONE NUMBER: (______) _______-__________
EMAIL: ________________________________________
CELL PHONE NUMBER: (______) _______-__________
SPOUSE
Name: __________________________
Date of Birth: _____/_____/______
Date of Marriage: _____/_____/______
Social Security Number:
_______-_____-_______
DEPENDENT CHILDREN
Is child 18-22 and
NAME
DATE OF BIRTH
IS CHILD DISABLED?
in school fulltime?
/
/
YES
NO
YES
NO
/
/
YES
NO
YES
NO
/
/
YES
NO
YES
NO
/
/
YES
NO
YES
NO
/
/
YES
NO
YES
NO
NOTE: Please provide a copy of:
1. Your Birth Certificate
2. Your Marriage Certificate
3. Your Spouse's Birth Certificate
4. Your Dependent Children’s Birth Certificates
5. If Divorced during period of employment:
a. Photocopy of complete Divorce Decree, or
b. Certified Copy of Plan-Approved Domestic Relations Order
6. Medical Documentation for Disabled Children. (If applicable)
nd
(NOTE: Please complete 2
page)
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