Form C4 - Application For Normal Retirement - 2011 Page 7
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22FORM C5-LB
CORRECTIONS OFFICER RETIREMENT PLAN
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016
(602) 255-5575 FAX (602) 296-2369
LOCAL BOARD DETERMINATION FOR DISABILITY RETIREMENT
Completed by Local Board
PRINT Employee/Member’s Name
SSN
LOCAL BOARD INSTRUCTIONS - Based on the “Type of Disability” selected by the employee on FORM C5-EE, complete the
applicable DISABILITY QUESTIONNAIRE (i.e., FORM C5-LB-A, FORM C5-LB-TP, or C5-LB-O).
Employer
Last Day
Termination Date
/
/
on Payroll
/
/
Service Date from
/
/
to
/
/
Service Break(s) from
/
/
to
/
/
Service Break(s) from
/
/
to
/
/
Work Status
Working Full-time
Not Working
Limited Duty
Unpaid Leave
(Select all that apply)
Working Part-time
Regular Assignment
Paid Leave
Other ____________________
DETERMINATION - Pursuant to A.R.S. § 38-893, the attached DISABILITY QUESTIONNAIRE and Medical Examination (if applicable),
the Local Board has determined that the employee/member:
Does not qualify for a disability retirement.
Qualifies for an ACCIDENTAL DISABILITY retirement pension effective
/
/
Qualifies for a TOTAL AND PERMANENT retirement pension effective
/
/
Qualifies for an ORDINARY DISABILITY retirement pension effective
/
/
Board Meeting Motion
PRINT Name of Local Board Secretary or Chairman
Signature
Date
Pursuant to § 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 is in compliance with statutory requirements.
LOCAL BOARD: Return ORIGINALS of this (C5-LB) form, C5-EE, DISABILITY QUESTIONNAIRE and provide the Medical
Examination (if applicable), Local Board meeting minutes and “REQUIRED DOCUMENTS” as indicated on FORM C5-EE.
Rev. 07/07/2011
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