Form C4 - Application For Normal Retirement - 2011 Page 17

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CORRECTIONS OFFICER RETIREMENT PLAN
FORM C14
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016
Page 1 of 1
(602)255-5575 FAX (602)296-2369
CERTIFICATION OF MARITAL STATUS
WITNESSETH:
I, the undersigned surviving spouse of ______________________________________________, do hereby attest and
certify that a valid and legal marriage, according to the laws of the State of Arizona, existed between the above-named
decedent and me at the time of the decedent's death. Said lawful marriage occurred on _______/_______/_______ and was
not legally terminated prior to my spouse's death on _______/_______/_______.
Signature of Surviving Spouse
STATE OF ARIZONA
)
)ss
County of _______________________________)
The foregoing instrument was acknowledged before me this __________ day of _________________,
20_____, by _____________________________________________________________________________.
Notary Public
My Commission Expires:

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