Standard Form 3112a - Applicant'S Statement Of Disability Page 10
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10Disability Retirement Application Checklist
For Disability Retirement Under the Civil Service Retirement System
and the Federal Employees Retirement System
Civil Service
Federal Employees
(to be completed by employing agency)
Retirement System
Retirement System
Form Approved: OMB No. 3206-0228
1. Name of applicant (last, first, middle)
2. Date of birth (mm/dd/yyyy)
3. Social security number
4. Do available records show that the employee has at least 5 years of civilian service under the Civil Service Retirement System or at least 18 months
under the Federal Employees Retirement System?
Yes
No
5a. Show the date pay stopped or will stop. (mm/dd/yyyy)
5. Will employee remain in duty status?
Yes
No
6. Has employee ever received or made application for compensation
6b. Period compensation was received.
6a. Claim number
from the Department of Veterans' Affairs?
From (mm/yyyy) To (mm/yyyy)
Yes
No
7.
7a. Has the employee made application for disability benefits from
7b. Is the application receipt or award notice attached?
FERS and CSRS
the Social Security Administration?
Offset Applicants
Yes
No
Yes
No
8. Are the following documents attached (Indicate by "X" for each).
Not
Yes
No
Applicable
a.
SF 2801 or SF 3107, Application for Immediate Retirement
b.
SF 3112A, Applicant's Statement of Disability
c.
SF 3112B, Supervisor's Statement
- Employee's Performance Standards
- Employee's Position Description
- Supporting documentation regarding employee's performance
- Supporting documentation regarding employee's leave use
- Supporting documentation regarding employee's conduct
d.
SF 3112C, Physician's Statement (or equivalent)
e.
SF 3112D, Agency Certification of Reassignment and Accommodation Efforts
- Supporting documentation of Agency's accommodation efforts
- Supporting documentation of employee's non-reassignment or non-selection
f.
Agency report of Federal medical examination (if one was made)
g.
Other:
9. Has the supervisor stated the employee's performance is less than fully successful in any critical element of the position in Section B, SF 3112B?
(1) a copy of the employee's performance appraisal covering the employee's service prior to the date shown in Section B,
Yes,
item 5, of the Supervisor's Statement, and
(2) a copy of the performance appraisal covering service after that date, if available.
No
10. If the employee is temporarily at an address other than the one given
11. If the employee is unable to act on his own behalf, give the name
on SF 2801 or SF 3107, Section A (such as hospital, nursing home,
and address of the person acting for him or her.
or with a relative), enter that address, including ZIP Code.
Agency Certification
13. Full Agency name and address (including ZIP Code)
12.
I certify that the information shown above accurately
reflects verified information in official records.
12a. Signature of Chief Personnel Officer or Designee
12b. Official title
14. List the full name and address of agency office and official to be
notified of OPM's determination (including telephone number and
area code).
12c. Email address
12d. Telephone number (incl. area code)
12e. Date (mm/dd/yyyy)
Check here if this address is the same as the address in item 13.
3112-103
Standard Form 3112E
U.S. Office of Personnel Management
Revised May 2011
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CSRS/FERS Handbook for Personnel and Payroll Offices
Previous edition is usable
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