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<br />CERTIFICATE OF DISABILITY <br />Fire Fighter's Relief & <br />Retirement Fund of <br />. Texas <br />411-D <br />T0: Firemen's Pension Commissioner <br />503-F Sam Houston Building <br />Austin, TX 78701 <br />(name in full) HEREBY makes application for disability <br />benefits in accordance with the provisions of S.B. 411, to be effective <br />The checks will be issued by the office of the Firemen's <br />Pension Commissioner. (IF eligible for both service retirement and disability <br />retirement benefits, applicant must select his preference, and this decision <br />is not reversible-Section 4). <br />DISABILITY BENEFITS: <br />1. The date of onset of disability is <br />2. Was the disability a result of the performance of your duties? <br />If yes, explain _ <br />3. Nature of the disability <br />4. Number of years in the department <br />5. Indicate number of fires number attended number of <br />drills number attended during the current calendar year. <br />6. Approximate date the fire fighter can return to his regular <br />employment <br />A DOCTOR'S STATEMENT SHOULD ACCOMPANY THIS FORM AND CONTAIN THE ABOVE INFORMATION. <br />An up-dated statement is required by law every three (3) months. <br />A record of this action is reflected in the minutes of the Board meeting on <br />(date) . <br />Fire Fighter's Signature <br />Social Security Number <br />Mailing Address <br />STATE OF TE~%AS <br />County of <br />Chairman of the Board <br />Secretary of the Board <br />Vice Chairman of the Board <br />SUBSCRIBED AND SWORN to me, the undersigned authority on this the <br />day of 19 <br />Notary in and for <br />County, Texas <br />Upon receipt of this form, it will be approved by the COMPIISSIONER; and a copy <br />will be mailed to you for your records. <br />Commissioner <br />Firemen's Pension Commissioner (Replaces forms 602 and 652) <br />