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This document includes the following forms:

» TRS ApplicATion foR DiSAbiliTy ReTiRemenT

» peeHip inSuRAnce AuTHoRizATion

» RSA DiRecT DepoSiT AuTHoRizATion

IMPORTANT INFORMATION

» The TRS ApplicAtion for DisAbility retirement must be received

at least 30 days and not more than 90 days prior to the

eective date of retirement.

» The report of DisAbility pAcket must also be received at least

30 days and not more than 90 days prior to the eective date

of retirement.

» The eective date of retirement must be the ﬁrst day of a

month.

» It is the responsibility of the member to ensure all forms are

mailed to the TRS.

If your career is cut short because of permanent disability, you may qualify for

monthly disability beneﬁts.

PART I of the DisAbility retirement ApplicAtion pAcket and the report of DisAbility pAcket are required to initiate the

disability retirement process. Once we receive your completed pArt i forms and your report of DisAbility pAcket,

the RSA Medical Board will meet to determine eligibility (the ﬁrst Tuesday of each month). If approved for disability,

the TRS will send the retirement ApplicAtion pAcket pArt ii. The retirement process is not complete until you have

returned the RSA ReTiRemenT benefiT opTion SelecTion form in pART ii.

Disability Retirement

Part I

Teachers’ Retirement System of Alabama

P.O. Box 302150 • Montgomery, Alabama 36130-2150 • 877.517.0020 • 334.517.7000 • www.rsa-al.gov

October 2020

Please contact Member Services at 877.517.0020 if you have

any questions.

Make sure that the TRS has your current home mailing

address. You can change your mailing address online

at https://mso.rsa-al.gov or by completing the

Address

ChAnge notifiCAtion form. Important information

regarding your retirement will be mailed from time to

time to your home mailing address.

Application Packet

Q. What is an annual disability review?

A disability retiree will be reviewed once each year for the

first five years and once every three-year period thereafter

until age 60 (age 52 for State Police) to determine whether

the retired member remains eligible for disability benefits.

If the

report of DisAbility pAcket is being completed for

the Annual Disability Review, the medical documentation

provided by your physician must be based upon a current

examination conducted within four months prior to

submission of the forms to the RSA. The completed forms

are to be returned to the RSA within 30 days of the initial

request.

Q. How do I cancel my retirement application?

Should you desire to cancel your TRS ApplicAtion for

DisAbility retirement, written notice must be given to the TRS

prior to your effective date of retirement. Failure to give

timely notice will result in an irrevocable application.

Questions?

» Visit RSA’s website at www.rsa-al.gov

» Email TRS through the RSA website; click on the

“Contact” link at the top of the page

» Call TRS at 877.517.0020

» Attend a TRS Retirement Preparation Seminar

FORM INSTRUCTIONS

1. Complete the first four sections of the TRS ApplicATion

foR DiSAbiliTy ReTiRemenT. Your employer may provide

certification through the Employer Self-Service Portal or

by completing the Employer Certification section of the

attached application.

2. Complete the peeHip inSuRAnce AuTHoRizATion form.

Please do not forget to sign this form where needed.

3. Complete the first page of the RSA DiRecT DepoSiT

AuTHoRizATion form. Send this form to your financial

institution to complete the second page. This form will

authorize the TRS to remit and credit your benefit directly

to your bank account and eliminate the possibility of your

check being lost or stolen.

4. Send the TRS ApplicATion foR DiSAbiliTy ReTiRemenT, PEEHIP

inSuRAnce AuTHoRizATion, and any other completed forms

to:

TRS

P.O. Box 302150

Montgomery, AL 36130-2150

Your TRS ApplicATion foR DiSAbiliTy ReTiRemenT must be received

by the TRS at least 30 days and not more than 90 days prior

to the effective date of retirement. The effective date of

retirement must be the first day of the month.

FREQUENTLY ASKED QUESTIONS

Q. How do I qualify for disability retirement?

To qualify for a disability benefit, the member must meet

all of the following conditions: (1) The member must have

10 years of creditable service. (2) The member must be

in-service. A member is considered in-service if currently

working or on official leave of absence, with or without

pay, for one year, which may be extended for no more

than one additional year. A member will not receive

service credit for periods of leave without pay. (3) The

RSA Medical Board must determine the member to be

permanently incapacitated for the further performance

of duty. The Medical Board bases its determination upon

information provided by the member’s physician. The

Medical Board normally meets on the first Tuesday in each

month.

Q. How are disability benefits calculated?

Maximum monthly disability retirement beneﬁts are

calculated identically to those for service retirement,

except that additional credit for sick leave cannot be

converted to retirement credit.

TRS Application for Disability Retirement

Teachers’ Retirement System of Alabama

PO Box 302150, Montgomery, Alabama 36130-2150

877.517.0020 • 334.517.7000 • www.rsa-al.gov

Your

Information

TRS_FORM10D

page 1 of 2

REV 10-2020

Retirement

Information

Sign Here è

Project/certify amount of wages for last 7 months

for which contributions will be submitted:

Jul Jan

Aug Feb

Sep Mar

Oct Apr

Nov May

Dec Jun

Your SSN

Name __________________________________________________________________________________________

First Middle/Maiden Last

Address _________________________________________________________________________________________

Street or P.O. Box City State ZIP Code

Telephone Number ___________________________ Email Address _________________________________________

Date of Birth ________________________________

Employer ___________________________________ Employer Telephone_____________________________________

Date of Retirement ___________________________ (This date is always the first of a month.)

*Final pay period end date _______________________________________

Enrollment end date (last work day) ________________________________

Last date of compensated employment _____________________________

Date of Termination ____________________________________________

Job Classification ______________________________________________

Contract salary for full year ______________________________________

Total wages (to be) paid

for current scholastic year _______________________________________

Total wages (to be) paid

after current scholastic year _____________________________________

Days worked/days contracted for current contract period ______________

Total accrued/unused sick leave days at date of retirement for which no lump-sum payment will be made ___________________

Employer Signature ______________________________________________________ Date ______________________

Beneficiary

Designation

Member

Authorization

Sign Here

Employer

Certification

Divorce or annulment

of a marriage shall

not revoke or void the

designation of a spouse

as beneficiary for any

benefits payable by RSA.

The beneficiary to whom I should like to receive any benefit due at my death _______________________________________

Relationship to me ___________________________________ Sex q Male q Female

Social Security Number ________________________________ Date of Birth ___________________________________

If the designated beneficiary listed above is different from that listed on my active account, make the change effective (check one):

q Upon the submission of this signed and notarized application to the TRS.

q On the date of my retirement.

Your Signature ______________________________________________________ Date __________________________

State of _______________________ , County of ____________________

On this _____ day of ______________________ , 20 __________, personally appeared before me, the above named

individual and acknowledged under oath that the statements made are true.

Signature of Notary Public ________________________________________ My Commission Expires ______________________

Please have your signature

acknowledged before a

Notary Public.

To be completed by the

employing agency

No contributions should

be made on lump-sum

leave pay.

*The final pay period end

date is the pay period end

date of the final paycheck.

TRS Application for Disability Retirement

PEEHIP Insurance Authorization

Teachers’ Retirement System of Alabama

PO Box 302150, Montgomery, Alabama 36130-2150

877.517.0020 • 334.517.7000 • www.rsa-al.gov

Members currently enrolled in PEEHIP Hospital Medical coverage, check the box which applies:

I wish to q continue or q cancel my PEEHIP Hospital Medical coverage.

Requested Date of Cancellation q Date of Retirement q End of Extra Coverage Months

I agree to have premiums deducted from my retirement check for any months that are due but were not deducted.

Your Signature ______________________________________________________ Date ___________________

The Center for Medicare and Medicaid Services (CMS) requires PEEHIP to maintain physical street addresses for all Medicare-eligible

members and dependents. If you have a P.O. Box number as your mailing address on page 1 of the trs ApplicAtion for DisAbility

retirement form, please provide us with your street address below. Receipt of this information is critical to ensure there are

no delays in processing your medical or prescription drug claims. Your street address will not be used as a permanent mailing

address, but will be maintained in our system for informational purposes to cooperate with CMS regulations. This update will not

change the address used to mail or deposit your retirement check.

Current Street Address

______________________________________________________________________________

Persons who are not insured on a PEEHIP Hospital Medical plan and are only enrolled in the Optional Coverage Plans (Dental,

Vision, Indemnity, and Cancer) can continue all four coverages or drop two Optionals at date of retirement. The retired state

contributions will pay the premium for two of the Optionals without a payroll deduction for those retirement members enrolled in

only the Optional Coverage Plans. If you are not currently enrolled in Optional Coverage Plans, you can only enroll during Open

Enrollment.

If you are only enrolled in the Optional Coverage Plans and wish to drop down to two plans, please indicate which two plans you

wish to keep on your date of retirement. To keep all four Optionals, mark “All.” You cannot drop only one and keep three except

during Open Enrollment.

q Dental q Vision q Indemnity q Cancer q All

I agree to have premiums deducted from my retirement check for any months that are due but were not deducted.

Your Signature ______________________________________________________ Date ___________________

embers from non-PEEHIP-participating universities and vested members applying for retirement:

You are eligible to enroll in hospital medical insurance through PEEHIP on your retirement.

PEEHIP will send you an information packet about PEEHIP and an enrollment form after the RSA receives your trs ApplicAtion for

service retirement or your trs ApplicAtion for DisAbility retirement.

Please note that you cannot enroll in PEEHIP Dental or other Optional Coverage plans at your retirement. Enrolling in these specific

plans must be done during annual Open Enrollment.

Hospital Medical

Information

Street Address

Information

Sign Here è

Member

TRS_FORM10D

page 2 of 2

REV 10-2020

Optional Coverage

Plans

Complete if enrolled

in Dental, Vision,

Indemnity, and/or

Cancer coverages

only.

Sign Here è

Member

Your SSN

Name ________________________________________________

Non-Participating

Universities

and

Vested Members

Not Currently

Enrolled

RSA Direct Deposit Authorization

Retirement Systems of Alabama

PO Box 302150, Montgomery, Alabama 36130-2150

877.517.0020 • 334.517.7000 • www.rsa-al.gov

Name __________________________________________________________________________________________

First Middle/Maiden Last

Address _________________________________________________________________________________________

Street or P.O. Box City State ZIP Code

Telephone Number ___________________________ Email Address ________________________________________

Date of Birth ________________________________

Check One: q Retiree q Beneficiary of Deceased Retiree or Member

If you are a beneficiary, please provide the following for the deceased retiree or member.

Name __________________________________________ SSN _____________________________

I agree to notify the Retirement Systems of Alabama (RSA) immediately of the death of the recipient of the retirement benefits being

deposited to this joint financial institution account, and to return all payments to the RSA that are deposited to this account after

said death. The RSA will determine and pay any survivor benefits. The RSA is authorized to make necessary debit entries to this joint

account for any credits that were made in error.

Joint Financial Institution Account Holder(s) Name(s) Joint Financial Institution Account Holder(s) Signature(s)

Date

____________________________________________

Each benefit payment is to be credited to my account at the financial institution specified on the reverse side of this form and such

payment will be in full payment, satisfaction, and discharge of the amount then falling due and payable to me on account of such

payments.

If my death occurs prior to the due date of any payment made by the RSA in compliance with this request or if adjustments are

required for any credit entries to my account, I authorize the RSA to make the necessary debit entries to my account. I hereby reserve

the right to revoke or cancel this request, such revocation or cancellation to take effect within 30 days of receipt of written notice by

the RSA.

I authorize my payment to be sent to the financial institution named on the reverse side of this form to be deposited to the

designated account.

Your Signature ______________________________________________________ Date ___________________

Your

Information

Account Holder

Certification

Signature

Certification

Sign Here è

No initials please

Direct Deposit from which System(s): q TRS q ERS q JRF q PEIRAF q RSA-1 (Annual or Monthly Distribution Only)

RSA_DDR

page 1 of 2

REV 7-19

Note: The retiree or beneficiary of a deceased retiree or member must complete this page.

Then take or mail both pages to your financial institution to verify your information.

Your financial institution must complete the second page and agree to the Master Agreement.

Indicate below

Your SSN the

system(s) from

which you

would like your

benefit(s) direct

deposited.

Your SSN

RSA Direct Deposit Authorization

Depositor Account No ______________________________________________ Bank Routing No ____________________

Financial Institution Name __________________ _________________________ Type of Account q Checking q Savings

Mailing Address ___________________________________________________________________________________

Street or P.O. Box City State ZIP Code

Name(s) of Person(s) on this Account

MASTER AGREEMENT

n accordance wi

th the provisions of Section 3.6.4 of the 2012 National Automated Clearing House Association (NACHA) Operating

Rules and Guidelines, both the Retirement Systems of Alabama (RSA), as the Originator, and the above named Financial Institution

consider the following to be the Master Agreement, as defined by the NACHA Operating Rules and Guidelines, and agree that it is to be

applicable to all payments sent by the RSA to the Financial Institution for the benefit of all benefit recipients having accounts with the

Financial Institution.

In consideration of the RSA making benefit payments in accordance with this Direct Deposit Authorization without requiring proof that

the retiree/beneficiary identified on this form is alive on the date on which such benefits are paid and are credited to his or her account,

the Financial Institution agrees to repay and refund to the RSA, on demand, the full amount of any payments made to and received by

the Financial Institution after the date of death of the benefit recipient, regardless of whether the account listed on this Direct Deposit

Authorization contains sufficient funds for the refund. The Financial Institution further agrees to accept the certification of the RSA as

to the date of death of such payee as sufficient evidence in accordance with Section 2.10 of the 2012 NACHA Operating Rules and

Guidelines.

I, the undersigned, confirm that the identity of the above named retiree/beneficiary, account number, and type are true and accurate.

As the representative of the above named Financial Institution, I certify that the Financial Institution agrees to receive and deposit the

identified payments in accordance with the Master Agreement and pursuant to Section 3.6.4 of the 2012 NACHA Operating Rules and

Guidelines, and that the Master Agreement is applicable to all payments sent by the RSA to the Financial Institution for the

benefit of the

retiree/beneficiary.

Representative

Name

_______________________________________________________________________________________

Representative Signature __________________________________________________ Date _____________________

Telephone Number ____________________________

Please return completed form to:

The Retirement Systems of Alabama

P.O. Box 302150

Montgomery, AL 36130-2150

Fax: 334.517.7001

Sign Here è

Financial

Institution

Financial

Institution

Information

Financial

Institution

Certification

RSA_DDR

REV 7-19

Note: Properly completed Direct Deposit Authorization forms received by the RSA

before the 13th of each month will be effective for the current month.

page 2 of 2

This page to be completed by a representative of the financial institution.

Name ________________________________________________ SSN

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