Form C4 - Application For Normal Retirement - 2011 Page 4
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22FORM C4D
Page 2 of 2
APPLICATION FOR DEFERRED ANNUITY
Name of
Member ________________________________
S.S.N. ________-______-________
Date _______/______/______
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 Local Board, 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 provision 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 annuity benefits.
________________________________________________
_______________________________________________
WITNESS SIGNATURE
MEMBER'S SIGNATURE
DATE _______/_______/______
EMPLOYER'S CERTIFICATION OF TERMINATION DATE:
Member's employment terminated on ___________________________________________________________________
BY_____________________________________________
Signature
_____________________________________________
Title
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