Disability Retirement Application

Name Last First MI Accidetal Ordiary Both Disability Retiremet Applicatio I N S T R U C T I O N S M A I N O F F I C E 500 Rutherford Ave., Suite 210 Charlestow, MA 02129-1628 Phoe 617-679-MTRS (6877) Fax 617-679-1661 W E S T E R N R E G I O N A L O F F I C E Oe Moarch Place Sprigfield, MA 01144-2048 Phoe 413-784-1711 Fax 413-784-1707 O N L I N E mass.gov/mtrs I order to apply for disability beefits, you must complete the questios ad forms cotaied i this applicatio. This applicatio cosists of: Overview of disability retiremet beefits.................. i iv Overview of retiremet optios ad calculatio worksheet................................. v vi Iformatio ad aswers you must provide............... 1 16 Authorizatios for release of iformatio Isurace records................................ 17 Protected health iformatio....................... 18 Tax records.................................... 19 Medical Pael selectio form............................ 20 Applicat s Physicia s Statemet...................... 21 26 If you have ay questios or eed clarificatio, please cotact our Disability Case Maager for help. Do ot delete ay pages from this applicatio. If ecessary, please attach additioal sheets. As required, please prit your resposes legibly, i ik. The 4 symbol meas that you must submit the documet listed i the margi alog with your applicatio. Be sure to complete the etire applicatio, icludig the release forms, ad attach all required documets before returig your applicatio to our office. If your applicatio is icomplete, we will retur it to you ad this will delay processig. We caot assig a date of applicatio which is very importat i determiig the effective date of your retiremet if your applicatio is approved util you have submitted all required iformatio. Your supportig physicia s completed statemet must be submitted at the same time that you file your applicatio or your applicatio will be cosidered icomplete ad your effective date of retiremet will ot be determied. Before you sed the applicatio ad your documets to us, make a photocopy of all pages for your records. After you have completed this applicatio, gathered the required documets ad made a photocopy for your records, please sed your materials to: Disability Case Maager Massachusetts Teachers Retiremet System 500 Rutherford Ave., Suite 210 Charlestow, MA 02129-1628

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page ii Accidetal Ordiary Both OVERVIEW OF DISABILITY RETIREMENT BENEFITS Accidetal Disability Retiremet Beefits What are the eligibility requiremets to apply for a accidetal disability retiremet allowace? You must have: bee a member i service at the time that you sustaied the persoal ijury or were exposed to the hazard that caused you to become permaetly disabled, ad sustaied the persoal ijury or bee exposed to the hazard while i the performace of your duties. What will I receive if I am grated a accidetal disability retiremet allowace? A accidetal disability retiremet allowace is made up of two compoets: a auity, a sum based o your cotributios to the MTRS ad the iterest o those cotributios, ad a regular pesio, a amout equal to 72% of your yearly compesatio as of the date you were ijured. For example, a teacher whose regular compesatio was $50,000 o the date of the work-related ijury that resulted i her permaet disability, ad who had a balace of $68,000 i her auity savigs accout, would receive a accidetal disability retiremet allowace of $41,165.28 per year. Auity Pesio Accidetal Disability Compoet + Compoet = Allowace $5,165.28 + $36,000 = $41,165.28/year (aual portio) (72% x $50,000) Please ote that this is oly a example of the calculatio of a accidetal disability retiremet allowace. Note: If you were hired after Jauary 1, 1988, your disability beefits will be capped at 75% of your yearly compesatio as of the date you were ijured. This meas that your total accidetal disability allowace the auity compoet plus the pesio compoet may ot exceed 75% of your last salary. Will I receive additioal beefits o behalf of my childre? Yes if you have ay depedet childre you will receive a additioal beefit of $450 per year per child, plus all of the cost-of-livig adjustmet icreases paid sice 1988. As of July 1, 2016, the additioal aual beefit for eligible childre was $871.56. A depedet child is a child uder age 18 or a child of ay age who is physically or metally icapacitated from earig. If your child reaches age 18 ad the cotiues his or her educatio o a fulltime basis, the stiped will cotiue util he or she reaches age 22. The MTRS will verify that your child is a full-time studet every semester util he or she reaches age 22. I am purchasig creditable service o the MTRS s istallmet paymet pla. If I am grated a accidetal disability retiremet before the ed of the istallmet pla term ad o loger eed ay additioal creditable service am I eligible for a refud of the moey I have already paid? No. Iteral Reveue Code provisios would prohibit a retur of ay amouts of cotributios already received ito your MTRS auity savigs accout. However, i may cases, you would ot be required to purchase the remaiig outstadig service. If this questio applies to you, please cotact the MTRS for additioal iformatio.

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page iii Accidetal Ordiary Both OVERVIEW OF DISABILITY RETIREMENT BENEFITS (cotiued) Does participatio i RetiremetPlus affect the calculatio of a accidetal disability retiremet allowace? No. If you elected to participate i RetiremetPlus ad have accrued 30 years of creditable service, at least 20 of which are teachig membership service, your accidetal disability retiremet beefit will be calculated as described o the previous page. However, you will ot receive a refud of the differece betwee the 11% cotributio rate ad your former rate or ay accelerated paymets already made. If you elected to participate i the RetiremetPlus program but do ot yet have 30 years of creditable service, your accidetal disability retiremet beefit will be calculated as described above ad the differece betwee the 11% ad your former rate of cotributio or the amout of accelerated paymets already made, will be refuded to you. Ordiary Disability Retiremet Beefits What are the eligibility requiremets to apply for a ordiary disability retiremet allowace? You are eligible to apply for ordiary disability beefits if you are: a military vetera, with at least 10 years of creditable service or ot a military vetera, ad i: Tier 1 (effective date of membership before April 2, 2012), ad uder age 55 with at least 10 years of service. Tier 2 (effective date of membership o or after April 2, 2012), ad uder age 60 with at least 10 years of service. What will I receive if I am grated a ordiary disability retiremet allowace? The ordiary disability retiremet allowace is calculated differetly depedig o whether you are a o-vetera or a vetera, ad whether you are participatig i RetiremetPlus ad eligible to receive the beefit of that program. No-vetera, o-retiremetplus participat If you are i Tier 1, ad uder the age of 55, the allowace is calculated as if you had retired at 55. If you are i Tier 2, ad uder the age of 60, the allowace is calculated as if you had retired at age 60. If you are age 55 (Tier 1) or age 60 (Tier 2) or over, your allowace is calculated accordig to your actual age. If you are uder the age of 55 (or 60) this works i your favor because, accordig to the retiremet formula, the older you are, the higher the multiplicatio factor ad the higher your beefit amout. While your age is advaced for calculatio purposes, you receive credit oly for the actual amout of service you have accrued as of the date of your retiremet. NOTE: for the retiremet factor tables ad a worksheet you ca use to estimate your beefits, please see page vi. For example, if you are i Tier 1 ad, retire uder a ordiary disability at age 45 with 20 years of creditable service, ad a three-year salary average of $50,000, you would receive $15,000 per year. Age Factor Number of Years Percetage (Age 55) x of Creditable Service = of Salary Average 0.015 x 20 = 30% Allowable Percetage 3-Year No-vetera, Ordiary Disability of Salary Average x Salary Average = Allowace (Optio A amout) 30% x $50,000 = $15,000/year No-vetera, RetiremetPlus participat ad eligible to receive the RetiremetPlus beefit If you elected to participate i RetiremetPlus ad have accrued 30 or more years of creditable service at least 20 of which are teachig membership service your allowace is calculated i the same way described above, with the exceptio that you receive the additioal RetiremetPlus percetage.

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page iv Accidetal Ordiary Both OVERVIEW OF DISABILITY RETIREMENT BENEFITS (cotiued) For example, if you are i Tier 1 ad retire uder a ordiary disability at age 54 with 30 years of creditable service, ad a three-year salary average of $50,000, you would receive $28,500 per year. Age Factor Number of Years Percetage (Age 55) x of Creditable Service = of Salary Average 0.015 x 30 = 45% Percetage RetiremetPlus Allowable Percetage of Salary Average + Percetage (if ay) = of Salary Average 45% + 12% = 57% Allowable Percetage 3-Year No-vetera, of Salary Average x Salary Average = RetiremetPlus Ordiary Disability Allowace (Optio A amout) 57% x $50,000 = $28,500 No-vetera, RetiremetPlus participat ad ieligible to receive the RetiremetPlus beefit If you elected to participate i the RetiremetPlus program but have ot yet accrued 30 years of creditable service at least 20 of which are teachig membership service your ordiary disability retiremet beefit will be calculated as described for a o-vetera, o-retiremetplus participat, above. I additio, you will receive a refud of your RetiremetPlus cotributios equal to the differece betwee the 11% rate ad your former rate of cotributio, plus ay accelerated paymets you may have made. If, however, you have accumulated a total of at least 30 years of creditable service, you will ot be eligible for a refud of your RetiremetPlus cotributios. Vetera, o-retiremetplus participat You receive a higher ordiary disability retiremet beefit tha a o-vetera. Your beefit is equal to a yearly auity amout plus oe-half of your salary for the last twelve moths durig which you were actually employed. Your yearly auity amout is based o the total of your cotributios to the retiremet system ad your iterest o those cotributios. For example, if your salary for the last year was $50,000 ad the balace i your auity savigs accout was $68,000, you would receive a aual allowace of $30,165.28. Auity Pesio Ordiary Disability Compoet + Compoet = Allowace $5,165.28 + $25,000 = $30,165.28/year (aual portio) (50% x $50,000) Vetera, RetiremetPlus participat ad eligible to receive the RetiremetPlus beefit If you elected to participate i the RetiremetPlus program ad have accrued 30 or more years of creditable service at least 20 of which are teachig membership service you will receive the higher of either the RetiremetPlus beefit (as calculated above for a o-vetera, RetiremetPlus participat ad eligible to receive the RetiremetPlus beefit) or the ordiary disability retiremet beefit for a vetera, o-retiremetplus participat. Vetera, RetiremetPlus participat ad ieligible for the RetiremetPlus beefit If you elected to participate i the RetiremetPlus program but have ot yet accrued 30 years of creditable service at least 20 of which are teachig membership service your ordiary disability retiremet beefit will be calculated as described for a Vetera, o-retiremetplus participat, above. I additio, you will receive a refud of your RetiremetPlus cotributios equal to the differece betwee the 11% rate ad your former rate of cotributio, plus ay accelerated paymets you may have made. If, however, you have accumulated a total of at least 30 years of creditable service, you will ot be eligible for a refud of your RetiremetPlus cotributios.

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page v Overview of retiremet Optios A, B ad C, tables ad factors, ad beefit estimate worksheet Overview of retiremet Optios A, B ad C The Massachusetts Retiremet Law (M.G.L. c. 32) regulates your retiremet allowace ad allows you to choose oe of three beefit optios. These optios differ with regard to the amout paid ad whether ay beefits will be paid to someoe else after your death. Optio Mothly beefit amout Survivor beefit A Maximum allowace Noe; all allowace paymets cease upo your death ad o beefits will be provided for ay survivors. B Approximately 1% less Oe-time, lump-sum paymet of balace, if ay, remaiig i member s auity savigs accout tha Optio A amout However, the older you are at Note: There are o restrictios o who or how may idividuals or etities may be amed as beeficiary. I most cases, the member s auity accout will be depleted 9 to 11 years after his or her retiremet date. retiremet, the higher the reductio percetage will be. C Approximately 9 11% less A mothly survivor beefit, equal to 2/3 of the retiree s mothly beefit at the time of death, paid to tha Optio A amout oe beeficiary. Note: Beeficiary must be the member s paret, child, siblig, spouse or former spouse who has ot remarried. Optio A age factor table Your Membership Tier Your age Tier 1 Tier 2 o your Established Established membership retiremet membership o or after 4/2/2012 date before 4/2/2012 41 0.001 42 0.002 43 0.003 44 0.004 45 0.005 46 0.006 47 0.007 48 0.008 49 0.009 50 0.010 51 0.011 52 0.012 53 0.013 54 0.014 55 0.015 56 0.016 57 0.017 58 0.018 59 0.019 With less tha With 30 years 30 years of or more of creditable service creditable service Tier 2 members are ot eligible Tier 2 members to retire util are ot eligible age 60 to retire util age 60 60 0.020 0.0145 0.01625 61 0.021 0.0160 0.01750 62 0.022 0.0175 0.01875 63 0.023 0.0190 0.02000 64 0.024 0.0205 0.02125 65 0.025 0.0220 0.02250 66 0.025 0.0235 0.02375 67+ 0.025 0.0250 0.02500 RetiremetPlus percetage table If you are participatig i RetiremetPlus, add the percetage that correspods to your umber of full years of creditable service (e.g., if you have 32.8 years of service, your RetiremetPlus percetage is the percetage listed for 32 years, ot 33 years. For the Optio C factor table, see page 32. Your Membership Tier Your full Tier 1 Tier 2 years of Established membership Established membership creditable before 4/2/2012 o or after 4/2/2012 service 30 12% 14% 31 14% 16% 32 16% 18% 33 18% 20% 34 20% 22% 35 22% 24% 36 24% 26% 37 26% 28% 38 28% 30% 39 30% 32% 40 32% 34%

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page vi Optio C factor table To obtai your Optio C factor, determie what your age will be o your birthday closer to your retiremet date; the determie what your beeficiary s age will be o his or her birthday that is closer to your retiremet date. Your Optio C factor is the umber where the row ad colum for your ages itersect. If the combiatio of your ages is ot listed here, please visit our website at mass.gov/mtrs or cotact us for the appropriate factor. To determie your closer age, cout the umber of moths ad days betwee your birthday before your date of retiremet, ad your ext birthday after your date of retiremet. Your closer age is your age o your birthday that is closer to your date of retiremet. For example, if you are retirig o Jue 30, ad your birthday is November 30, your closer age is your age o your birthday after your retiremet date. Determiig your ad your beeficiary s closer ages Beeficiary s closer age 11/30/17 Your 59th birthday 6/30/18 7 moths 5 moths Your retiremet date 11/30/18 Your 60th birthday: your closer age Member s closer age Member s closer age Beeficiary s closer age 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 50.9509.9528.9546.9565.9583.9601.9618.9635.9652.9669.9685.9700.9715.9730.9744.9758.9771.9783.9796 51.9460.9480.9500.9520.9539.9558.9577.9596.9614.9632.9650.9667.9683.9699.9715.9730.9744.9758.9772 52.9408.9429.9450.9471.9492.9512.9533.9553.9573.9592.9611.9630.9648.9665.9683.9699.9715.9730.9745 53.9350.9372.9395.9417.9440.9462.9484.9506.9527.9548.9569.9589.9609.9628.9646.9665.9682.9699.9716 54.9287.9311.9335.9359.9383.9406.9430.9453.9477.9499.9522.9544.9565.9586.9606.9626.9645.9664.9682 55.9219.9244.9270.9295.9320.9346.9371.9396.9421.9445.9470.9493.9517.9539.9562.9583.9604.9625.9644 56.9146.9173.9199.9226.9253.9280.9307.9334.9360.9387.9413.9438.9463.9488.9512.9536.9559.9581.9603 57.9068.9096.9124.9152.9181.9209.9238.9267.9295.9323.9351.9379.9406.9433.9459.9484.9509.9534.9558 58.8984.9013.9043.9073.9103.9133.9163.9194.9224.9254.9284.9314.9343.9372.9400.9428.9455.9482.9507 59.8895.8925.8956.8987.9019.9051.9083.9115.9147.9179.9211.9243.9274.9305.9336.9366.9395.9424.9452 60.8800.8831.8863.8896.8929.8963.8997.9031.9065.9099.9133.9167.9200.9233.9266.9299.9330.9361.9392 61.8699.8732.8765.8799.8834.8869.8904.8940.8976.9012.9048.9084.9120.9156.9191.9225.9260.9293.9326 62.8592.8626.8661.8696.8732.8769.8806.8844.8882.8920.8958.8996.9034.9072.9110.9147.9184.9220.9256 63.8481.8516.8551.8588.8626.8664.8703.8742.8782.8822.8862.8902.8943.8983.9023.9063.9102.9141.9179 64.8364.8400.8437.8475.8513.8553.8594.8635.8676.8718.8760.8803.8846.8888.8931.8973.9015.9057.9098 65.8241.8278.8316.8355.8395.8436.8478.8521.8564.8608.8653.8697.8742.8787.8832.8877.8922.8967.9011 66.8113.8151.8190.8230.8271.8314.8357.8401.8446.8492.8539.8585.8633.8680.8728.8775.8823.8870.8917 67.7980.8018.8058.8099.8142.8186.8230.8276.8323.8370.8419.8468.8517.8567.8617.8667.8717.8768.8817 68.7840.7879.7920.7962.8006.8051.8097.8144.8192.8242.8292.8343.8394.8446.8499.8552.8605.8658.8711 69.7694.7734.7776.7819.7863.7909.7956.8005.8055.8105.8157.8210.8264.8318.8373.8428.8484.8540.8596 70.7542.7582.7624.7668.7713.7760.7808.7858.7909.7962.8015.8070.8125.8182.8239.8297.8355.8414.8473

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page vii Member ame Beefit estimate worksheet ad examples Formula Your Membership Tier You as of You as of / / / / Example: Tier 1 Examples: Tier 2 Established Established membership membership o or after 4/2/2012 before 4/2/2012 With less tha With 30 years 30 years of or more of creditable service creditable service Optio A Optio B Optio C Optio A Age Age age factor Age 58 Age 60 Age 60 (see table) 0.018 0.0145 0.01625 x Years of creditable service x x x 35 x 28 x 30 Base % of salary average % % 63.00% 40.60% 48.75% + RetiremetPlus %, Participatig Participatig Participatig % % if applicable* + + + 22.00% + 0.00% + 14.00% Total % of salary average** % % 80.00% 40.60% 62.75% x Salary average 3-yr sal avg 5-yr sal avg 5-yr sal avg Tier 1, 3-yr; Tier 2, 5-yr x $ x $ x $75,000 x $70,000 x $70,000 Optio A $ $ aual allowace $60,000 $28,420 $43,925 + Vetera s $ $ beefit*** + + + $300 + $300 + $300 Fial Optio A $ $ aual allowace $60,300 $28,720 $44,225 Fial Optio A $ $ aual allowace $60,000 $28,420 $43,925 x 99% (1% less tha Optio A)**** x 99% x 99% x 99% x 99% x 99% Optio B $ $ aual allowace $59,400 $28,136 $43,486 + Vetera s $ $ beefit*** + + + $300 + $300 + $300 Optio B aual allowace $ $ $59,700 $28,436 $43,786 Optio A aual allowace $ $ $60,000 $28,420 $43,925 x Optio C Factor Be. age 57 Be. age 59 Be. age 59 (see table) x x x 0.9194 x 0.9099 x 0.9099 Optio C $ $ aual allowace $55,164 $25,859 $39,967 + Vetera s beefit*** + $ + $ + $300 + $300 + $300 Fial Optio C $ $ aual allowace $55,464 $26,159 $40,267 x 2/3 (survivor portio) x 2/3 x 2/3 x 2/3 x 2/3 x 2/3 Aual membersurvivor beefit $36,976 $17,439 $ $ $26,845 * If you are participatig i RetiremetPlus, ad you have 30 or more years of creditable service at least 20 of which are membership service with the MTRS or the Bosto Retiremet System as a teacher eter the appropriate percetage from the RetiremetPlus percetage table. ** Your Total % of salary average may ot exceed 80 percet. *** If you are a wartime vetera, $15 for each year of teachig service (up to a maximum of $300) is added to the Optio A aual allowace. **** The Optio B allowace is approximately 1% less tha the Optio A amout. For purposes of illustratio oly, we have estimated the Optio B amout at 1% less tha the Optio A amout. However, the older you are at retiremet, the higher the reductio percetage will be.

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 1 Member ame S E C T I O N 1 APPLICANT DATA Type of disability retiremet applied for........ Accidetal Ordiary Both Social Security umber, XXX-XX-XXXX.......... Member umber.......................... 4 All marriage certificate(s) ad/or proof of ame chage(s) sice birth record (photocopy OK) Geder.................................. Male Female Name Prefix, if ay First Middle Last Suffix, if ay Former/maide ame, if applicable 4........ 4 Birth certificate (must be certified; photocopy ot accepted) Date of birth 4, mm/dd/yyyy............. Mailig address Number ad street Apt. Home phoe ( ) E-mail 4 Military discharge form DD214 Marital status............................. Married Sigle Divorced Widowed Vetera status............................ Novetera Vetera 4....................................... Dates of active military service: mm/yyyy....................................... From to....................................... Total year(s) MTRS RetiremetPlus status.................. Noparticipatig Do t kow....................................... Participatig (elected i)....................................... Participatig (madated) Alterate address: If you will be residig at a address other tha the oe above (for example, a summer or retiremet address) withi the ext 12 moths, please list below. Alterate address Number ad street Apt. S E C T I O N 2 ATTORNEY DATA mm/yyyy mm/yyyy Phoe ( ) Dates here: From to If you are represeted by a attorey i this disability retiremet applicatio process, please provide the followig iformatio so that we may cotact him or her as ecessary. If applicable Name Prefix, if ay First MI Last Suffix, if ay Firm Address Number ad street Suite/Floor Phoe ( ) Fax ( )

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 2 Member ame S E C T I O N 3 APPLICANT S STATEMENT I,, hereby make applicatio for disability retiremet beefits pursuat to Massachusetts Geeral Laws, c. 32, sectios 6 or 7. The icapacity described is ot the result of serious or willful miscoduct o my part. If I am applyig for accidetal disability beefits, I state that the icapacity described herei ad i the writte materials accompayig this applicatio, was sustaied as a result of a ijury or hazard that I uderwet as a result of my employmet ad while i the performace of my duties. I do hereby certify that this statemet, together with the statemets made herei ad o the writte materials accompayig this applicatio, are made uder the pais ad pealties of perjury ad are true ad accurate to the best of my kowledge ad belief. I ackowledge that this applicatio is made subject to Chapter 32 of the Massachusetts Geeral Laws ad titles 807 ad 840 of the Code of Massachusetts Regulatios. I additio, I certify that I have ot bee charged, or idicted, or covicted of a crime ivolvig laws applicable to my positio pursuat to M.G.L. c.32 15. Applicat s Sigature Date S E C T I O N 4 EMPLOYMENT HISTORY Curret positio (positio you are retirig from) Title School district Grade(s) taught Dates employed From to Date whe you last worked mm/yyyy mm/yyyy School Phoe ( ) Fax ( ) Name of superitedet Name of pricipal Name of immediate supervisor Phoe ( ) Phoe ( ) Phoe ( ) Creditable service estimate Please idicate your approximate umber of years of creditable service.......

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 3 Member ame S E C T I O N 4 EMPLOYMENT HISTORY (cotiued) All Previous Employmet Please list all previous employmet i chroological order, begiig with your oldest positio ad edig with your curret positio. If you have ever bee employed by ay other Massachusetts state govermetal agecy or uit, you may be eligible to purchase creditable service for that employmet. If you list the Commowealth of Massachusetts as a previous employer, please check the box i the last colum (MA public service). Period of employmet Employer s ame/ If MA public From To address service, (mm/dd/yyyy) (mm/dd/yyyy) please box S E C T I O N 5 PRIMARY TREATING PHYSICIAN Please idetify the physicia who has provided you with primary care i coectio with your disability. You must cotact this physicia to otify him or her that the MTRS requires that he or she complete the Physicia s Statemet icluded herei (pages 21-26), ad provide him or her with these pages. Your physicia the must complete the statemet, ad you must submit it to the MTRS with your disability retiremet applicatio. Note: If you are applyig for disability retiremet based o more tha oe coditio, you must list oe primary physicia for each coditio. If this applies to you, please check the box, below, ad attach a separate sheet. Primary treatig physicia s ame Last First Middle Address Number ad street Phoe ( ) Additioal coditio(s) ad primary physicia(s): Please see attached sheet for additioal physicia listig(s).

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 4 Member ame S E C T I O N 6 DISABILITY AND DUTIES Please state the medical reaso which is the cause of your applicatio for disability. Please describe the essetial duties which you are required to perform i your curret positio. How frequetly are you required to perform the essetial duties you described above? Please describe the essetial duties which you are uable to perform as a result of your disability. S E C T I O N 7 RECENT PHYSICAL ACTIVITIES For the period of the last year, please describe your physical activities, icludig: Medical rehabilitatio activities Other employmet activities sice the oset of your disability Sports activities Activities of daily livig (for example, drivig, cleaig, etc.)

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 5 Member ame S E C T I O N 8 WORKER S COMPENSATION We advise that you read this sectio carefully. It cocers the right of the MTRS to offset your disability retiremet pesio beefit by the amout of certai outside paymets you may receive for the same ijury. Pursuat to Massachusetts Geeral Laws, chapter 32, s. 14(2), the MTRS has the authority to offset from your disability pesio the followig paymets you may receive as a result of the same ijury for which you receive a disability pesio: Ay ad all Workers Compesatio disability paymets which you receive uder Massachusetts Geeral Laws, chapter 152, ss. 31 (survivor s beefits), 34 (temporary total), 34A (permaet ad total), 34B (COLA), 35 (temporary partial) ad 35A (depedet s beefits). Ay recovery for lost wages you may receive from a third party other tha your employer. The statute also requires that you cooperate with the MTRS both i filig for ad receivig Workers Compesatio beefits ad pursuig ad reportig ay third party paymets. If you do ot cooperate i this regard, the MTRS has the authority to susped your disability pesio ad/or file for Workers Compesatio or other beefits o your behalf. Please ote: You are required to otify the MTRS as to ay chage i rate of your Workers Compesatio beefit (icludig, but ot limited to chages i COLA) or prior to ay settlemet of your Workers Compesatio or third-party (i.e., persoal ijury) claim. Failure to do so may result i a overpaymet for which you will be liable. Have you applied for Workers Compesatio beefits?.......... Yes No If yes, date you applied for Workers Compesatio, mm/dd/yyyy If o: Please be aware that you must apply for Workers Compesatio beefits. Are you applyig for a accidetal disability retiremet?........ Yes No Have you received or are you receivig Workers Compesatio beefits or a settlemet?.................................. Yes No 4 Copy of your settlemet agreemet If yes, please provide the followig iformatio: Type of Workers Compesatio receivig or received.................... Weekly beefits Settlemet 4 Date of iitial paymet, mm/dd/yyyy........ Amout of paymet as part of a weekly/ biweekly beefits or settlemet........... Type of icapacity...................... Total Partial Receivig Workers Compesatio COLA?... Yes No If yes, please provide the date you first received a COLA................. Name of attorey for Workers Compesatio Isurer.............................. Name ad phoe umber of the Workers Compesatio isurace adjuster/claims represetative for the school district/tow or, if self-isured, ame ad phoe umber of the Workers Compesatio aget for the school district/tow.......................... ( )

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 6 Member ame S E C T I O N 9 SALARY DATA 4 Cotract 4 Cotract 4 Cotract 4 Cotract 4 Cotract 4 Cotract I order for us to calculate your potetial disability retiremet beefits, we eed iformatio regardig your regular compesatio. If you are: A Tier 1 member (effective membership date prior to April 2, 2012), please report either your three highest cosecutive years regular compesatio or your last three years regular compesatio, whichever is greater. A Tier 2 member (effective membership date o or after April 2, 2012), please report either your five highest cosecutive years regular compesatio or your last five years regular compesatio, whichever is greater. Please also: Report your cotracted salary for the year immediately before the three or five years reported. Submit copies of your cotracts verifyig your regular compesatio listed here. Be sure to iclude paymet schedules or cotractual laguage to substatiate ay earigs i excess of your regular cotract rates. From (mm/dd/yyyy) School Year To (mm/dd/yyyy) Regular Compesatio 4 4 4 4 4 4 $ As of the date of this applicatio,............. Paid leave Sick bak what is your salary status?................... Upaid leave Workers Compesatio If you are a vetera, please also list your regular compesatio for the last 12 moths. 4 Cotract 4 Cotract S E C T I O N 1 0 DEPENDENT CHILD DATA From (mm/dd/yyyy) School Year To (mm/dd/yyyy) Regular Compesatio 4 4 Please record the ames, birth dates ad Social Security umbers of your childre who are: uder age 18; over age 18 ad physically or metally icapacitated from earig; ad over age 18 ad uder 22 who are full-time studets. $ Name Geder Date of birth Social Security Status (check oe) (first MI last) (mm/dd/yyyy) umber Uder Icapacitated Studet 18 over 18 18 22 M M M M F F F F

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 7 Member ame S E C T I O N 1 1 YOUR RETIREMENT OPTION SELECTION, STATEMENT AND SIGNATURE IMPORTANT NOTE If you have ever bee divorced, ad you have a qualified Domestic Relatios Order (DRO), ad the terms of your DRO specify the retiremet optio that you must choose, please be sure to complete this sectio i accordace with your DRO. Complete Optio A moth-of-death paymet recipiet desigatio (Sectio 13 o page 9 of this applicatio) Complete Optio B beeficiary desigatio (Sectio 14 o page 9 of this applicatio) Please select your retiremet Optio ad provide the required iformatio. Note: Be sure that you have reviewed the iformatio o our website or o page v of this applicatio regardig the beefits provided by each of the three available retiremet optios. Please estimate your beefits usig page ii vi of this applicatio before you fialize your optio selectio. Oce you have filed this applicatio, you caot chage your retiremet optio. Because of this fact, it is importat that you uderstad the retiremet optios that are available to you ad that you make a iformed decisio based o your fiacial eeds ad the fiacial eeds of your family. Please mark your optio choice below. Your retiremet applicatio is ot complete util the MTRS receives this completed sectio. If you have ay questios, please cotact our office. I, the udersiged, havig applied for retiremet from the Massachusetts Teachers Retiremet System, hereby elect to receive my retiremet allowace uder the optio selected below (check oe): Optio A Optio A provides the maximum beefit allowace amout, ad o survivor beefits. All mothly paymets cease upo your death ad o beefits will be provided for ay survivors. If, after your death, ay beefits that you eared i the moth of your death are due, they will be paid i a lump sum to the moth-of-death paymet recipiet(s) that you should desigate by completig Sectio 13 o page 9 of this applicatio. Optio B Optio B provides a beefit allowace that is approximately 1 percet less tha the Optio A allowace. Upo the member s death, it also provides for the lump-sum paymet of the remaider of the member s auity savigs accout, if ay, to the amed beeficiary or beeficiaries; i most cases, the member s auity accout will be depleted 9 to 11 years after his or her date of retiremet. You may chage your beeficiary desigatio at ay time durig your retiremet by completig ad submittig a ew, revised Beeficiary Form Retired Member/Optio B to the MTRS. If you select Optio B, you must desigate your Optio B beeficiary(ies) by completig Sectio 14 o page 9 of this applicatio. Optio C Optio C provides a beefit allowace that is geerally 9 to 11 percet less tha the Optio A allowace. Upo the member s death, it also provides a mothly survivor beefit to oe amed beeficiary that is equal to 2/3 of the retiree s mothly beefit at the time of death. If you are selectig Optio C, you must desigate your Optio C beeficiary here: Name of Optio C beeficiary. First M. Last. Optio C beeficiary s birth certificate (must be submitted, ad must be certified; photocopy ot accepted) Marriage certificate(s) (photocopy OK) Beeficiary s date of birth... mm/dd/yyyy. Relatioship to you................ Paret Siblig Child Spouse............................... Former spouse who has ot remarried You may ot chage your Optio C beeficiary desigatio after your effective date of retiremet. I the evet that your Optio C beeficiary predeceases you, cotact the MTRS so that we may adjust your beefit to the higher, Optio A pop-up amout. I have selected the optio checked above ad uderstad that I caot chage my optio selectio after filig this applicatio. Additioally, I uderstad that regardless of whe I receive my Notice of Estimated Retiremet Beefit (NERB), I caot chage my optio selectio after filig this applicatio. I uderstad that I must file my optio selectio makig the best estimate I ca usig the tools that the MTRS has provided, icludig those provided with this applicatio. I also uderstad that I may cotact the MTRS with questios. SSN Applicat s sigature r Date Name (please prit) SSN NOTE: Eve if you do ot expect to be married o your iteded date of retiremet, you MUST also complete Sectio 12, Spousal ackowledgmet.

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 8 Member ame S E C T I O N 1 2 SPOUSAL ACKNOWLEDGMENT You MUST complete Sectio a, below, ad the, if applicable, your spouse must complete sectio b. If your spouse s whereabouts are ukow, you must complete a otarized affidavit (available upo request from the MTRS s mai office), icludig your spouse s last kow address. a) I, the udersiged, havig applied for retiremet from the Massachusetts Teachers Retiremet System, have elected to receive my retiremet allowace uder the optio selected i the previous sectio. I hereby certify that (check all that apply): Í! N O T E : ALL applicats must sig ad complete this sectio! Í! * This sectio must be completed ad siged ON OR AFTER the date that the member completed ad siged Part 1, Sectio 11 (page 7). If your spouse ad/or witess sig this sectio before the date that the member siged Part 1, Sectio 11, we will retur the applicatio to the member to have this page completed ad siged agai. I am ow married or expect I have bee divorced ad it is my I am NOT curretly married to be married as of my uderstadig that there ad do ot expect to be iteded date of retiremet is is ot do t kow married as of my iteded as stated i this applicatio. a Domestic Relatios Order o file date of retiremet as stated Please sig ad date this with the MTRS. i this applicatio. Please sig sectio, the give this form Please sig ad date this sectio, ad date this sectio, the to your spouse for the retur your etire applicatio retur your etire applicatio completio of sectio b. to the MTRS. to the MTRS. I subscribe uder the pealties of perjury that the above iformatio is true, complete ad correct to the best of my kowledge. Applicat s sigature Date* Name (please prit) SSN b) As the spouse of a member who is retirig from the MTRS, you are etitled to both otificatio ad explaatio of the retiremet optio selected by the member. You must sig Sectio b before oe witess; the member amed i Sectio a, above, caot be your witess. The witess must sig ad date the form o the same day that you do; it is ot ecessary that your witess be a Notary Public. Before completig this sectio, please see which retiremet optio your spouse has chose i the previous sectio, ad the read the explaatios of the available retiremet optios as provided o pages v ad vi of this applicatio ad o our website at mass.gov/mtrs. Please be sure that you have read ad uderstad the various provisios of the optio selected by your spouse, specifically, the beefits to which you may or may ot be etitled to upo his or her death. If you have ay questios, do ot hesitate to cotact the MTRS for a explaatio. If you fail to sig this Spousal ackowledgmet, the MTRS will otify you withi fiftee (15) days by registered mail of the optio selected by your spouse ad your right to sig ad retur the spousal ackowledgmet withi thirty (30) days. Failure to sig ad retur the Spousal Ackowledgmet to the Massachusetts Teachers Retiremet System withi 30 days will result i your spouse s selectio becomig effective without your sigature. I, the udersiged, am the spouse of the member amed i Sectio a, above, who has applied for retiremet from the Massachusetts Teachers Retiremet System. I hereby certify uder the pealties of perjury that: I have read ad uderstad the iformatio o Optios A, B ad C, ad I am aware of the optio selected by the applicat ad uderstad the provisios of that optio. Spouse s sigature Date* Name (please prit) SSN WITNESS TO SPOUSE SIGNATURE (must be witessed by someoe other tha the member) I subscribe uder the pealties of perjury that the member s spouse (the perso amed immediately above) persoally appeared before me ad siged this form i my presece. Witess s sigature r r r Date* Name (please prit) Address.........

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 9 Member ame S E C T I O N 1 3 OPTION A MONTH-OF-DEATH PAYMENT RECIPIENT(S) Optio A provides o survivor beefits. However, after your death, if ay beefits that you eared i the moth of your death have ot bee paid out, they will be paid i a lump sum to your moth-ofdeath paymet recipiet(s). Please ame the desigee(s) to receive the lump-sum paymet of ay beefits that you ear i the moth of your death below. Please see the shaded box at bottom of this page for additioal iformatio. Type (check oe) SSN or tax ID % of paymet Perso Date of birth. Relatioship to you...... Trust or orgaizatio You should complete this sectio if you have selected Optio A oly. Name Address % Perso Date of birth. Relatioship to you...... Trust or orgaizatio Name Address % SECTION 14 OPTION B BENEFICIARY DESIGNATION Total sum of percetages listed for all PRIMARY Optio A moth-of-death paymet recipiets must equal 100% You must complete this sectio if you have selected Optio B oly. Optio B provides a beefit allowace that is approximately 1 percet less tha the Optio A allowace. Upo your death, it also provides for the lump-sum paymet of the remaider of the member s auity savigs accout, if ay, to the amed beeficiary(ies); i most cases, the member s auity savigs accout will be depleted withi 9 to 11 years after his or her retiremet date. Please see the shaded box at bottom of this page for additioal iformatio. Type (check oe) SSN or tax ID % of beefit Perso Date of birth. Relatioship to you...... Trust or orgaizatio Name Address % Perso Date of birth. Relatioship to you...... Trust or orgaizatio % Name Address Total sum of percetages listed for all PRIMARY Optio B beeficiaries must equal 100% Optio A ad B retirees ONLY: Additioal iformatio ad optioal cotiget desigee(s) You may chage your desigatio at ay time durig your retiremet; simply complete ad submit a Beeficiary Desigatio Form for Retirees. You may ame more tha oe perso or etity. If you do ame more tha oe primary desigee, however, please be sure to idicate the percetage that each primary etity should receive (the total must equal 100%). If you fail to idicate a percetage, we will distribute the amout equally amog the primary etities. If the total does ot equal 100%, the differece will be paid to your estate. If you eed more space to idicate additioal etities, please make a photocopy of this page, complete the appropriate lie(s), sig each additioal sheet, ad, i this box, idicate how may additioal sheet(s) are attached............................. OPTIONAL CONTINGENT DESIGNEE(S): If you wish, you may also ame cotiget desigee(s). I the evet that the primary desigee(s) amed above are ot alive at the time of your death, ay beefit amout due will be paid to your cotiget desigee(s). If ay of your primary desigees predecease you, they are replaced by a cotiget desigee, i the order i which you ame them, below (the remaiig primary beeficiaries shares do ot icrease if oe of them predeceases you, or is that share equally split amog the multiple cotiget beeficiaries). If there is o cotiget beeficiary who is presetly livig, that share is paid to your estate. Type (check oe) SSN or tax ID Perso Date of birth. Relatioship to you...... Trust or orgaizatio Name Address

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 10 Member ame STOP S E C T I O N 1 5 REASON FOR ACCIDENTAL DISABILITY If you are applyig for retiremet based o: Ordiary disability oly, skip to Sectio 23 (Medical history) o page 15 Accidetal disability oly, or both accidetal ad ordiary disability, please cotiue with Sectio 15 below Oe of the coditios for receivig approval of your applicatio for accidetal disability retiremet beefits is that the Board must fid that the disability is the atural ad proximate result of either the persoal ijury you sustaied (usually, oe or several specific icidets) or the hazard udergoe (geerally, exposure to a harmful situatio over a period of time). Please idetify the reaso for your disability...... Persoal ijury Hazard or exposure....................................... sustaied udergoe Beig as specific as possible, please describe either the persoal ijury you sustaied or the hazard/exposure udergoe Date(s) Specific time(s) or if hazard/ exposure, legth of time exposed Locatio(s) Descriptio of icidet(s) or hazard/exposure Please describe the job duties you were performig immediately prior to ad durig the time of the persoal ijury you sustaied or the hazard/exposure udergoe

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 11 Member ame S E C T I O N 1 6 WITNESS DATA Did ayoe witess the icidet(s) or hazard/exposure described above?. No Yes If yes, please provide the followig iformatio for each witess: Name Last First MI Address Number ad street Apt. PO Box Phoe ( ) Relatioship to applicat Name Last First MI Address Number ad street Apt. PO Box Phoe ( ) Relatioship to applicat Name Last First MI Address Number ad street Apt. PO Box Phoe ( ) Relatioship to applicat S E C T I O N 1 7 INCIDENT REPORTS Have you filed a report of the icidet(s) or hazard/exposure described above with ay perso or agecy?....................... No Yes If yes, please provide the followig iformatio for each perso or agecy. Name Last First MI Agecy 4 Claim or icidet report Address Number ad street Phoe ( ) Date report filed 4 Name Last First MI Agecy 4 Claim or icidet report Address Number ad street Phoe ( ) Date report filed 4

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 12 Member ame S E C T I O N 1 8 INSURANCE COVERAGE Do you have ay isurace coverage which relates to the icidet(s) or hazard/exposure described above?.................... No Yes If yes, please provide the followig iformatio for each policy. Additioally, please ote: The MTRS requires that you sig a Authorizatio for the release of isurace records. This form is o page 17 ad allows the MTRS to request copies of your isurace records from the isurers you list below for the period of the last five years. Aget s ame Last First MI Agecy Address Number ad street Phoe ( ) Type of coverage Aget s ame Last First MI Agecy Address Number ad street Phoe ( ) Type of coverage S E C T I O N 1 9 EMERGENCY MEDICAL TREATMENT Did you receive emergecy medical treatmet as a result of the icidet(s) or hazard/exposure described above?.................... No Yes If yes, please provide the followig iformatio for each physicia from whom you received treatmet. Additioally, please ote: The MTRS requires that you sig a authorizatio for the release of protected health records. This form is o page 18 ad allows the MTRS to request copies of your medical records from the facilities ad physicias you list below. Treatig physicia s ame Last First MI Hospital/facility Address Number ad street Phoe ( ) Date(s) of treatmet Treatig physicia s ame Last First MI Hospital/facility Address Number ad street Phoe ( ) Date(s) of treatmet

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 13 Member ame S E C T I O N 2 0 MEDICAL TREATMENT Have you received ay medical treatmet as a result of the icidet(s) or hazard/exposure described above?.................... No Yes If yes, please provide the followig iformatio. Additioally, please ote: The MTRS requires that you sig a authorizatio for the release of protected health records. This form is o page 18 ad allows the MTRS to request copies of your medical records from the facilities ad physicias you list below. Primary care physicia s ame Last First MI Address Number ad street Phoe ( ) Date(s) of treatmet Nature of treatmet Primary care physicia s ame Last First MI Address Number ad street Phoe ( ) Date(s) of treatmet Nature of treatmet Did you take ay time off from your employmet?.................. No Yes If yes, please list date(s) ad time(s) Did your physicia(s) recommed ay rehabilitatio?................ No Yes If yes, please describe ay rehabilitatio you have udergoe

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 14 Member ame S E C T I O N 2 1 OTHER ACTIONS TAKEN As a result of the icidet(s) or hazard/exposure described above, did you file a grievace pursuat to your collective bargaiig agreemet?......... Not applicable No Yes If yes, please describe the status of your grievace As a result of the icidet(s) or hazard/exposure described above, was ay admiistrative or discipliary actio take by your employer?... No Yes If yes, please explai As a result of the icidet(s) or hazard/exposure described above, did your employer coduct ay tests or studies o ay area of the school buildig or grouds or make ay repairs i such areas?.............. Not applicable No Yes If yes, please explai S E C T I O N 2 2 OTHER CONDITIONS Cotributig coditios or evets Please describe ay other circumstaces, evets or physical coditios that cotributed or may have cotributed to your disability.

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 15 Member ame S E C T I O N 2 3 MEDICAL HISTORY The followig sectios relate to ay medical treatmet you have received. Prior illesses, accidets or ijuries Please list all prior illesses, accidets or ijuries you have had, begiig with the oldest occurrece ad edig with the most recet oe. Date(s) From To Descriptio of illess, accidet or ijury Medical treatmet (mm/dd/yyy) (mm/dd/yyy) received Hospitals, medical facilities or istitutios Please list all hospitals, medical facilities or istitutios which you have cosulted or at which you received ay treatmet, begiig with the oldest occurrece ad edig with the most recet oe. Additioally, please ote: The MTRS requires that you sig a authorizatio for the release of protected health records. This form is o page 18 ad allows the MTRS to request copies of your medical records from the facilities you list below. Date(s) Name of facility/ From To Address/ Reaso for visit (mm/dd/yyy) (mm/dd/yyy) Phoe umber

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 16 Member ame S E C T I O N 2 3 MEDICAL HISTORY (cotiued) Physicias Please list all physicias whom you have cosulted or from whom you received ay treatmet, begiig with the oldest cosultatio ad edig with the most recet oe. Additioally, please ote: The MTRS requires that you sig a authorizatio for the release of protected health records. This form is o page 18 ad allows the MTRS to request copies of your medical records from the physicias you list below. Date(s) Name of physicia/ Reaso for From To Address/ cosultatio (mm/dd/yyyy) (mm/dd/yyyy) Phoe umber S E C T I O N 2 4 PAID AND UNPAID LEAVES As a result of time away from your employmet, if ay, because of your disability, have you take ay paid sick leave?...... No take ay paid vacatio time?.. No take ay upaid sick leave?.... No take ay upaid leave?....... No Yes; from to Yes; from to Yes; from to Yes; from to

M T R S D I S A B I L I T Y R E T I R E M E N T A P P L I C A T I O N Page 17 Member ame S E C T I O N 1 Mai Office 500 Rutherford Aveue, Suite 210 Charlestow, MA 02129-1628 Phoe 617-679-MTRS (6877) Fax 617-679-1661 Olie mass.gov/mtrs Applicat s authorizatio for release of Isurace Records APPLICANT S STATEMENT AND AUTHORIZATION FOR RELEASE OF INSURANCE RECORDS To be completed by the applicat Re:_ Name of applicat/record subject Number/street Social Security umber Date of birth I authorize the MTRS to submit this release to, ad to request my isurace records from, ay isurer or agecy I have listed i this Disability Retiremet Applicatio. Additioally, I uderstad that if the isurer or agecy charges ay fee for providig these records, I will be resposible for the paymet of such fee. If I do ot agree to pay, I uderstad that my applicatio may ot be processed. I authorize the below-amed idividual, isurer or agecy to release to the Massachusetts Teachers Retiremet System ay ad all iformatio, reports ad records it may have regardig ay applicatio or claim for isurace I have made durig the five (5) years precedig the date beside my sigature, below. The scope of this authorizatio icludes the release ad copyig of such iformatio, reports ad records, icludig but ot limited to: correspodece, applicatio forms, claim forms ad medical examiatios. A photocopy of this documet, icludig my sigature, shall be as valid ad effective as the origial. S E C T I O N 2 ) REQUEST FOR INSURANCE RECORDS To be completed by the MTRS Sigature Keeper of the Records Date Name of isurer ad/or agecy Number/street Name of record subject s employer/group Policy/certificate umber Date of Please forward request records by To the Keeper of the Records: You have bee amed as havig provided isurace coverage by the above-oted idividual i his or her applicatio for disability retiremet. I accordace with the above authorizatio, please submit your isurace records regardig this idividual, by the forwardig date idicated, directly to: Disability Case Maager Massachusetts Teachers Retiremet System 500 Rutherford Ave., Suite 210 Charlestow, MA 02129-1628 Please iclude a copy of this sheet with ay records that you sed us. If you have ay questios, please cotact the Disability Case Maager immediately at 617-679-6877. Thak you for your cooperatio ad assistace.