Form C4 - Application For Normal Retirement - 2011 Page 15
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C12
Page 1 of 1
3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016
08/11
(602)255-5575 FAX (602)296-2369
DATE
NOTIFICATION OF BENEFITS AND ELECTION
RETIRED: ____/____/____
MEMBER'S NAME: ________________________________ DATE FIRST PAYMENT DUE: _______/_______/_______
PAYABLE TO: _____________________________________________________________________________________
(Name of Member, Survivor or Guardian)
TYPE OF BENEFIT:
Normal Retirement
Survivor
Guardian
Total & Permanent Disability
Accidental Disability
Ordinary Disability
I. BENEFITS UNDER ARIZONA CORRECTIONS OFFICER RETIREMENT PLAN:
a). Monthly pension payable to Member (A.R.S. Section 38-885 or Section 38-886) . . . . . . . . . $ _______________
b). Monthly pension payable to surviving spouse or guardian:
(If applicant is a member, the spouse's benefit shown here will be payable
upon death of the retired member. The spouse's benefit ceases upon death;
the guardian's/child's benefit ceases when child reaches age 18.)
(A.R.S. Sections 38-887 or 38-888 or 38-904) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________
II. BENEFITS FROM PRIOR LAW:
The applicant may elect to receive the following benefits because of membership
under a prior law in lieu of the above. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________
The Local Retirement Board has met on _______________ and determined that the applicant above is eligible for the
benefit payment as shown above:
(date)
_______________________________________________
_______________________________________________
Name of Local Board
Signature of Board Chairman or Secretary
Election and Acceptance by Member or Survivor
(Choose appropriate line below)
I ELECT TO ACCEPT the type of pension benefit reflected above as well as the amount of benefits as determined under
ITEM I above, representing the benefits payable to me and to my survivors under the Arizona Corrections Officer
Retirement Plan.
I ELECT TO RECEIVE the benefits under ITEM II in accordance with the prior law designated as
__________________________________________________________________.
I UNDERSTAND that this election to receive benefits pursuant to this document and under the CORP or another system may
not be revoked and is binding upon me or any beneficiary or survivor unless otherwise provided by law.
_______________________________________________
_______________________________________________
Witness Signature
Signature of Member, Survivor or Guardian/Child
_______________________________________________
Dated: _______/_______/_______
Signature of Spouse (if Item II has been selected)
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