Form C4 - Application For Normal Retirement - 2011 Page 2
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22FORM C4
Page 2 of 2
APPLICATION FOR NORMAL RETIREMENT (Continued)
MEMBER’S
NAME: ___________________________ S.S.N.: _________-______-____________ DATE: _______/_______/______
DATE OF BIRTH: ___________________
1. LEAVE(S) WITHOUT PAY: During my period(s) of covered service, I have been on leave of absence without pay as
indicated below:
(a) None
Missed Pay Periods
Employer
1.
(b)
2.
3.
4.
5.
2. INDUSTRIAL LEAVE: During my period(s) of covered service, I have received compensation benefits under the
Worker's Compensation Laws of the State of Arizona as indicated below:
(a)
None
(b)
From ______/______/_______
Through ______/______/_______
Employer ___________________
From ______/______/_______
Through ______/______/_______
Employer ___________________
From ______/______/_______
Through ______/______/_______
Employer ___________________
3. The information contained above is true, complete and correct to the best of my knowledge and belief. Further, I HEREBY
AUTHORIZE the office of the board of trustees and/or their authorized designee to procure from my employer(s) or from
any other person, firm or corporation (including any governmental agency or department thereof) any and all information as
directly related to leave(s) of absence without pay and/or application(s) for and/or receipt of Worker's Compensation
Benefits. I expressly waive all provisions of law forbidding any doctor, person, firm or corporation (including any
governmental agency or department thereof) from disclosing any knowledge or information which they have in their
possession concerning leave(s) of absence without pay and/or Worker's Compensation.
This is a limited release and is only to be in effect from this date to 120 days after first receipt of my retirement benefits.
________________________________________________
_______________________________________________
WITNESS SIGNATURE
MEMBER'S SIGNATURE
DATE: _______/_______/______
EMPLOYER'S CERTIFICATION OF RETIREMENT DATE:
The above-named member's employment will terminate on _______/_______/_______
By: _______________________________________________________________
Dated: _______/_______/_______
Employer's Authorized Signatory
Title: ____________________________________
Witness: ______________________________________________
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