Form C4 - Application For Normal Retirement - 2011 Page 6
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C5-EE
Page 2 of 2
3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016
08/11
(602) 255-5575 FAX (602) 296-2369
APPLICATION FOR DISABILITY RETIREMENT
Completed by Employee
REQUIRED
AUTHORIZATIONS AND UNDERSTANDING – Initial the following:
_______ I authorize and request each physician and person in the medical or related fields, and each hospital, clinic, establishment and
place rendering or having in the past rendered to me any medical or related service to allow the Local Board, the office of the Board of
Trustees of the Corrections Officer Retirement Plan (CORP), their authorized designee, and/or each physician appointed by them to have,
examine and/or copy, any and all information, records, reports and x-rays, regarding my physical and/or mental condition and treatment
therefore.
_______ I 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.
_______ I understand that pursuant to A.R.S. § 38-893(H), the Board of Trustees may perform a review of the disability retirements to
ensure that the employee/member and the Local Board are in compliance with statutory requirements.
Authorizations are in effect from the date of this application to 120 days after first receipt of retirement benefits.
WAIVER OF CONFIDENTIALITY
_______ I hereby consent, upon the advice of counsel, that all matters and issues relating to my physical or mental condition or medical
history, including, without limitation, whether my physical or mental condition arises from any preexisting disability, may be discussed and
considered by the Board of Trustees and/or Local Board in open public meeting, and I hereby waive any right to have my physical or mental
condition or medical history discussed and evaluated by the Board of Trustees and/or Local Board in executive session only. As part of the
aforesaid waiver, I further consent that the Board of Trustees and/or Local Board may discuss and consider all evidence touching upon my
physical or mental condition or medical history in open public session, including without limitation, testimony or records concerning my
physical or mental condition or medical history from physicians or other expert witnesses, the social security administration, the state
industrial commission, or other sources or persons of any kind or description. I understand that neither the Board of Trustees nor the Local
Board has any obligation to keep confidential any information about my physical or mental condition or medical history that is discussed,
presented or considered during any public session of the Board of Trustees or Local Board, and I absolve the Board of Trustees and Local
Board from any liability arising from disclosure of such information during public session.
I hereby submit my application for a disability pension subject to all of the terms and conditions of the CORP. I attest that all information
submitted is true, complete and correct to the best of my knowledge and belief. I understand that A.R.S. § 38-912(C) states: “A person who
knowingly makes any false statement or who falsifies or permits to be falsified any record of the system with an intent to defraud the system
is guilty of a class 5 felony.”
/
/
Date
Employee/Member’s Signature
Local Board Representative Signature
REQUIRED DOCUMENTATION (as applicable, provide your Local Board with a copy):
1.
Birth Certificate
5.
If divorced during period of employment:
2.
Marriage Certificate
a. Photocopy of complete Divorce Decree, or
3.
Spouse's Birth Certificate
b. Certified copy of Plan-approved Domestic Relations Order
4.
Dependent Child(ren) Birth Certificates
6.
Medical documentation for disabled children.
Received Stamp or PRINT Name and Signature of Local Board Representative
Date
EMPLOYEE: Copy for your records and send ORIGINAL to your Local Board.
Rev. 07/07/2011
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