Free 17295.PDF - Indiana

STATEMENT OF SUPERINTENDENT DISABILITY BENEFITS APPLICATION
State Form 17295 (R2/2-02) Approved by State Board of Accounts 2002

Indiana State Teachers' Retirement Fund
150 West Market St. Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860/ Toll Free: (888) 286-3544 Fax: (317) 232-3882 http//www.in.gov/trf PRIVACY NOTICE Your Social Security Number is requested by this state agency in order to meet requirements of IRS Code 3405. Disclosure is mandatory; this form will not be processed without it.

INSTRUCTIONS: This form must be on file at ISTRF prior to applicant being considered for disability benefits. APPLICANT INFORMATION (Applicant to complete and deliver to his/her superintendent) TRF Number Street Address State Zip Code SUPERINTENDENT'S STATEMENT (Superintendent to complete and return to ISTRF) 2. Applicant has been under my supervision for:

Social Security Number

Name of Applicant

City

1. 3.

I have personally known the applicant for:

Information, to my personal knowledge, concerning applicant's physical condition:

4.

In my opinion, applicant is incapacitated for duty as a teacher. (circle one) YES NO

5.

Applicant is under contract to our school corporation. (circle one) YES NO

Please read the following carefully prior to completing questions 6, 7, and 8. * Compensation includes all sick leave pay received by this applicant from your school corporation . When furnishing the dates below, please list the name of the month; do not refer to any month by designating a number. It is important that the dates below are accurate. 6. Date* compensation ceased (month, day, year) 9. 7. Date applicant last taught (month, day, year) 8. The semester in which this teacher last taught ended: (month, day, year)

What is your opinion on whether or not the applicant should be granted a disability pension?

Comments:

Name of school unit

Signature of superintendent

Date signed

Name and title if other than Superintendent