Free 21703.pdf - Indiana


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Date: May 22, 2009
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State: Indiana
Category: Government
Author: IGONZALES
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http://www.state.in.us/icpr/webfile/formsdiv/21703.pdf

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AFFIDAVIT OF APPLICANT FOR DISABILITY BENEFIT
State Form 21703 (R5 / 5-09) Approved by State Board of Accounts, 2009

INDIANA STATE TEACHERS' RETIREMENT FUND 150 West Market Street, Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / Toll-free (888) 286-3544 Fax: (317) 232-3882 / E-mail: [email protected] Web site: www.in.gov/trf

PRIVACY NOTICE
Your Social Security number is being requested by this agency pursuant to the requirements of IRS Code 3405. This disclosure is mandatory and this form cannot be processed without this information

MEMBER DATA
Name (last, first, middle) Address City State ZIP Code Social Security number Date of birth (mm/dd/yyyy) TRF number Telephone number with area code E-mail address

This is a new address
Employer city or township

LAST EMPLOYER INFORMATION
Last employer Last date of active teaching service
(mm/dd/yyyy)

Employer county Your age at beginning service

Last teaching position

Date covered service began
(mm/dd/yyyy)

President of Board or Trustee of last employer Address of President of Board or Trustee of last employer

Superintendent of last employer Address of Superintendent of last employer

MEDICAL INFORMATION
Date medical condition began
(mm/dd/yyyy)

Date you gave up your teaching position (mm/dd/yyyy) Date a half school year will have elapsed since you quit teaching
(mm/dd/yyyy)

Date you first consulted a physician for this condition (mm/dd/yyyy) Time lost during last teaching year because of your condition Address of attending physician

Date your last school year ended
(mm/dd/yyyy)

Date your next school year starts
(mm/dd/yyyy)

Earnings, if any, since you ceased public school work

Name of attending physician you first consulted for this condition

How did your disability begin? State fully all the symptoms and describe your condition from onset of symptoms:

Do you expect such confinement to continue? Yes No Describe, in detail, to what extent you are incapacitated from continuing in the teaching profession. Are you confined to bed? Yes No Are you confined to a Yes No house?
(mm/dd/yyyy)

Date such confinement, if any, began

What ailments, diseases, illnesses, disorders, infirmities, disabilities or injuries have you had in the last five years? Give complete facts, dates of onset, and the name and address of any physician who attended you in each case.

Have you ever been an inmate of a hospital, asylum, sanitarium, or health resort of any kind? If so, give dates, sites, and full particulars.

CONTINUED ON NEXT PAGE

MEDICAL INFORMATION (Continued) During the last five years have you received a pension from any source, or benefits from any accident or health insurance company or association? If so, give dates, names, addresses and full particulars.

Give name and address of every physician and/or specialist you have consulted during the last three years.

Have you made claim to any insurance company for benefits because of your condition? If so, give name and address of each such insurance company.

Are you able to appear before the examining physician in Indianapolis? If not, can you appear before an examining physician in your area? MEMBER AFFIDAVIT

Yes Yes

No No

I hereby acknowledge that I understand the terms of this affidavit and any ambiguities herein are to be resolved in favor of the Indiana State Teachers' Retirement Fund. I hereby acknowledge that I have had ample time and opportunity to secure legal counsel for the purpose of explaining any of these declarations contained within. I affirm, under the penalties for perjury, that the foregoing representation(s) is (are) true.
Member's signature Member's name (printed) Date (mm/dd/yyyy)

NOTARY PUBLIC CERTIFICATION State of _________________________________ SS: County of _______________________________ Before me the undersigned, a Notary Public for ________________________ County, State of __________________,
Officer's county of residence

personally appeared _____________________________________ and they, being first duly sworn by me upon his/her
Name of person

oath, say that the facts alleged in the foregoing instrument are true. Signed and sealed this _______ day of ______________________________, 20_______. __________________________________________________
Signature

__________________________________________________
Name of officer (printed or typed)

My commission expires: _____________________ (SEAL)

OFFICE USE ONLY
Processed by Date (mm/dd/yyyy) Audited by Date (mm/dd/yyyy) IC 5-10.4-5-1