Application For A Disability Allowance Page 6
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12CT TEACHERS’ RETIREMENT BOARD
765 ASYLUM AVENUE HARTFORD, CT 06105-2822
“An Affirmative Action/Equal Opportunity Employer”
Toll-Free 1-800-504-1102
(860) 241-8416
Fax (860) 622-2848
MEMBER PERSONAL STATEMENT FOR DISABILITY ALLOWANCE
You are required to submit a handwritten statement outlining the effect your illness has on your ability
to perform your job duties and your day to day personal activities. Please be as specific as possible.
Name of Applicant
Social Security #
I am applying for a Disability Allowance due to:
A Physical Impairment
(Please check one)
A Mental Impairment
Both a Physical and a Mental Impairment
___________________________________________________________________________________________________
Applicant’s Signature
Date
MEMBER'S PERSONAL HANDWRITTEN STATEMENT:
You may add additional pages as necessary. Please do not write on the back of this form or on the
back of any additional forms.
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