Form C4 - Application For Normal Retirement - 2011 Page 3
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C4D
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016
Page 1 of 2
(602)255-5575
FAX (602)296-2369
APPLICATION FOR DEFERRED ANNUITY
TO: LOCAL RETIREMENT BOARD
DATE: _______/_______/_______
Having completed 10 or more years of credited service with the (employer name) ___________________________________,
and having attained age 62, I, (name) ________________________________________, hereby submit my application for a
deferred annuity under the terms of the Arizona Corrections Officer Retirement Plan (A.R.S. Section 38-911). I am terminating
on or have terminated on (date) _______/_______/_______, acknowledging that the effective date of my deferred annuity will
be the first day of the month following the date of application, with payments beginning on or about the last day of that month. I
also understand that if I die and I have accumulated contributions remaining in the system, those remaining accumulated
contributions will be paid to my designated beneficiary, if living, or to my nearest living kin as selected by my local CORP board.
ADDRESS:_____________________________________
HOME PHONE NUMBER: (______) _______-__________
_______________________________________________
WORK PHONE NUMBER:(______) _______-__________
EMAIL:_________________________________________
CELL PHONE NUMBER:(______) ______ -__________
NOTE: Please provide a copy of:
1.
Your Birth Certificate
2.
Your Marriage Certificate
3.
Your Spouse’s Birth Certificate
4.
Your Dependent Children’s Birth Certificate
5.
If Divorced during period of employment:
a. Photocopy of complete Divorce Decree, or
b. Certified copy of Plan-approved Domestic Relations Order
nd
(NOTE: Please complete 2
page)
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