Form C4 - Application For Normal Retirement - 2011 Page 12
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C7S
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016
(602)255-5575 FAX (602)296-2369
Page 1 of 1
APPLICATION FOR A SURVIVOR'S BENEFIT
DATE: _______/_______/_______
TO: LOCAL RETIREMENT BOARD
I hereby submit my application for a survivor's benefit under the terms of the Arizona Corrections Officer Retirement Plan.
NAME OF
DATE
DECEASED MEMBER: __________________________________________
OF DEATH: _______/_______/_______
RELATIONSHIP TO DECEASED:
SURVIVING
GUARDIAN OF DECEDENT'S
SPOUSE
DEPENDENT CHILDREN
SURVIVING SPOUSE:
NAME: ____________________________________________________ DATE OF BIRTH: _______/_______/_______
SOCIAL SECURITY NUMBER: ________-______-________ DATE OF MARRIAGE: _______/_______/_______
MAILING ADDRESS: ________________________________________________________________________
HOME PHONE NUMBER: (_____) ______-________
WORK PHONE NUMBER: (_____) ______-_______
EMAIL: __________________________________________
CELL PHONE NUMBER: (_____) ______-_______
GUARDIAN:
NAME: ___________________________________________ SOCIAL SECURITY NUMBER: _______-_____-_______
DATE OF BIRTH: _______/_______/_______
MAILING ADDRESS: ________________________________________________________________________
HOME PHONE NUMBER: (_____) ______-________
WORK PHONE NUMBER: (_____) ______-_______
EMAIL: __________________________________________
CELL PHONE NUMBER: (_____) ______-_______
SURVIVING CHILDREN OF DECEASED:
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.
Death Certificate
2.
Birth Certificate (for spouse, dependent children, and guardian)
3.
Marriage Certificate (if applicable)
4.
Proof of Legal Guardianship (if applicable)
5.
Medical Documentation for Disabled Children. (If applicable)
6.
Proof of Fulltime School Enrollment (If applicable)
7.
Social Security Card
The information contained in this application is true, complete and correct to the best of my knowledge and belief.
_____________________________________________
________________________________________________
Witness Signature
Signature of Spouse or Guardian
Date Received by Employer
Employer
Signature of Employer
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