Free 10564.FH11 - Indiana

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APPLICATION FOR DISABILITY BENEFITS
1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND
State Form 10564 (R2 / 8-08)

1977 POLICE OFFICERS & FIREFIGHTERS PENSION & DISABILITY FUND 143 West Market Street Indianapolis, Indiana 46204-2899 Toll Free: 1-888-526-1687

* This agency is requesting disclosure of Social Security Numbers in accordance with IRS code; disclosure is mandatory and this form will not be processed without it.

INSTRUCTIONS:

1. Please type or print. 2. Please submit a copy of the birth certificate. Documents showing the date of birth may be a photocopy of a birth certificate, a baptismal or confirmation certificate, or a court decree. Attach an English translation to any foreign document. 3. Please have this application notarized. 4. All of the above items must be provided; this application will not be processed without them. TO BE COMPLETED BY APPLICANT

Full name (first, middle, last) Address (number and street, city, state, and ZIP code) Telephone number Social Security Number * If married, name of spouse (first, middle, last)

Date of application (month, day, year)

Date of birth (month, day, year)

(

)
Married Single
Date of birth of spouse (month, day, year) Municipality account number Date of hire (month, day, year) Have you received or will you receive any other income while on disability?

Marital status (check one) Social Security Number of spouse * Municipality where employed Type of disability

Converted member
Source of income

77 Fund

Disabled after left force
Amount of income

Yes

No

I hereby depose and say that: I am the person who made the foregoing statements; I have carefully read the questions and the answers thereto and understand the same; the information provided is full, complete and true, and no material fact has been concealed or omitted therefrom; and that this application is made for presentation to the board of trustees of the 1977 Police Officers and Firefighters Pension and Disability Fund in making claim for the benefits I am entitled to according to 1977 pension fund statutes.
Signature of applicant Printed name Date (month, day, year)

CERTIFICATION OF NOTARY PUBLIC

STATE OF ___________________________________ SS: COUNTY OF _______________________________

The above information was subscribed and sworn to before me, a notary public, in and for the state and county above named, by the applicant, who is to me personally known, on this ____________ day of _____________________________________, 20________.
Signature of notary public County of residence Printed name of notary public Date commission expires (month, day, year)

TO BE COMPLETED BY LOCAL PENSION BOARD
Disability period Last day of full pay from the Department (month, day, year) Class of disability

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CERTIFICATION OF EMPLOYER I hereby certify that the individual named below is a member of the city and department listed below and is covered by the 1977 Pension Fund. I further certify that there is no suitable and available work, considering reasonable accommodations pursuant to the Americans with Disabilities Act (where applicable), for which he/she is or may be capable of becoming qualified. Should this individual return to work, I will notify the 1977 Police Officers and Firefighters Pension and Disability Fund in writing.
Name of member (first, middle, last) Department Signature of chief City Work status

Able
Telephone number

Unable

(

)

Date (month, day, year)

Please indicate, where appropriate, any employee contributions or employer-paid employee mandatory contributions which have been deducted from pay and are either on a quarterly report in transit or will be reported in the future. Do not accumulate figures. Show amounts only by quarter for each quarter still to be reported. Please always indicate this information for the quarter that includes the last day in pay status. No estimates can be accepted. Quarter Wages Paid Contribution

I hereby certify the above information for _________________________________________________________.
Name of employee Title Signature of city controller / clerk treasurer / trustee Date (month, day, year)

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