Form C4 - Application For Normal Retirement - 2011 Page 11
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C7D
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016
(602)255-5575 FAX (602)296-2369
APPLICATION FOR DEATH BENEFIT
DATE: _______/_______/_______
TO: LOCAL RETIREMENT BOARD
I hereby submit my application for a death benefit under the terms of the Corrections Officer Retirement Plan.
NAME OF
DATE
DECEASED MEMBER: __________________________________________
OF DEATH: _______/_______/_______
APPLICANT'S NAME: ______________________________________
SOCIAL SECURITY NUMBER: ________-______-________
DATE OF BIRTH: _______/_______/_______
RELATIONSHIP TO DECEASED:
Designated
Personal Representative of
Beneficiary
Decedent’s Estate
MAILING ADDRESS: _______________________________________________________________________________
(Street)
(Apt. No.)
(City)
(State)
(Zip)
HOME PHONE NUMBER: (_____) ______-________ WORK PHONE NUMBER: (_____) ______-________
EMAIL: _____________________________________ CELL PHONE NUMBER:
(_____) ______-________
Enclose
Copy of Death Certificate
:
Copy of Applicant’s Driver's License
Certified Copy of Personal Representative letter (if applicable)
Federal and State Withholding Forms
Copy of Applicant’s Social Security Card
Form U3 Benefits Lump Sum Distribution (if applicable)
Special Tax Notice Copy to Applicant (if applicable)
The information contained in this application is true, complete and correct to the best of my knowledge and belief.
__________________________________________
___________________________________________________
Witness Signature
Signature of Designated Beneficiary or Personal Representative
Final contribution amount to CORP _________________ for Pay Period Ending: ___________________________
Employer: ____________________________________________________
_______/_______/_______
______________________________________________
Date Received by Employer
Signature of Employer
Total amount of benefit $_______________________________________________
The Local Retirement Board has met on ____________ and determined that the applicant above is eligible for the benefit
payments as shown above:
(date)
_______________________________________________
_______________________________________________
Name of Board
Signature of Board Chairman
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