Imrf Form 5 40 – Fill Out and Use This PDF

1. File an Application for Disability Benefits (IMRF Form 5.40) with IMRF. We recommend you submit your application directly to IMRF.

•You can also fax your application to IMRF at 630-706-4289.

•File the form even if you filed a worker’s compensation claim.

•Print your Social Security number on all documents you enclose with the form.

MAILED

FAXED

____________________________________________

DATE YOU FILED

2. Call your employer and ask them to file an Employer’s Statement with

IMRF (IMRF Form 5.41). Your employer should have the form. If not, they can download the form from www.imrf.org.

•Write down the name of the person you spoke with and the date.

•Ask when the employer thinks the form will be submitted to IMRF.

____________________________________________

PERSON YOU SPOKE WITH

____________________________________________

DATE

____________________________________________

DATE EMPLOYER WILL SUBMIT

3. Provide your physician(s) (the first physician who examined you for this

disabling condition) with a Physician’s Statement of Disability Claim

(IMRF Form 5.42) and have your physician(s) submit the documentation to IMRF, with copies of your medical records from the date of

disability.

•Write down the name of the person you spoke with and the date.

•Ask when the physician(s) will complete the form and submit it to IMRF.

____________________________________________

PERSON YOU SPOKE WITH

____________________________________________

DATE

____________________________________________

DATE PHYSICIAN WILL SUBMIT

Who does what in this process?

•You need to print your Social Security number on all documents you send to IMRF (e.g., your birth certificate).

•Your employer needs to file an Employer’s Certificate of

Disability (IMRF Form 5.41).

•Your physician(s) needs to file a Physician’s Statement of

Disability (IMRF Form 5.42). You must provide the physician(s) with the form.

•If your doctor releases you to return to work on a part-time basis, you should refer to “Trial Work Period” in the IMRF

Disability Benefits booklet.

Instructions for completing Questions 1 - 11

Q 1A, 1B, 1C Enter the requested information. If you do not

answer question 1B, you will delay processing of your claim. If appropriate, answer question 1C.

Q 2 Enter the last date you worked. Do not file this claim if you are still working. If you will be disabled due to a planned event (e.g., elective surgery, pregnancy), submit this form after your last day at work. If you do not

answer question 2, you will delay processing of your claim.

Q 3A, 3B, 3C If appropriate, enter the requested information.

Q 4 Answer either yes or no.

Q 5 Answer yes or no and, if appropriate, enter the requested information.

Q 6 Answer either yes or no. And, if appropriate, indicate status of claim—check all that apply.

Q 7 Answer either yes or no.

Q 8 Answer yes or no and, if appropriate, enter the requested information.

Q 9, 9A Answer yes or no and, if appropriate, enter the requested information.

Q 10 Enter the name, address, and phone number of each doctor you saw and the date of each visit.

Q 11 Enter the name, address, phone number, and dates of treatments for each hospital in which you were treated.

This question serves as a substitute IRS Form W-4P.

IMRF disability benefits are subject to federal income tax.

IMRF must withhold income tax unless you elect on line 12a not to have tax withheld.

If you elect to have income tax withheld, complete line 12b. If you complete line 12b and also want an additional amount withheld from your monthly disability benefit payments, enter this

amount on line 12c.

CAUTION: Remember that there are penalties for not paying enough tax during the year. For more information, please see IRS Publication 505, “Tax Withholding and Estimated Tax,” available from most IRS offices or from www.irs.gov.

•You may use IRS Form W-4P in lieu of Question 12. Form W-4P is available online at www.irs.gov and at most IRS offices.

Purpose

Unless you elect otherwise, federal income tax will be withheld from your disability benefit. The law requires that unless

you tell IMRF otherwise, tax will be withheld on IMRF monthly

payments as if you are married and claiming three withholding

allowances. To view the tax amount to be withheld under current regulations, read “Tax Letter #13,” at www.imrf.org under “Publications.”

You can use this certificate (Question 12) to instruct IMRF to do any of the following:

•To withhold no tax from your disability payments.

•To withhold taxes based on the number of allowances and marital status you indicate.

•To withhold an additional amount you specify from each payment.

Your tax withholding instruction stays in effect until you change or revoke it. IMRF must notify you each year of your right to elect to have no tax withheld or to revoke your election.

Statement of income tax withheld from your disability payments

By January 31 of next year, you will receive a statement (1099-R) from IMRF showing the total amount of your disability payments and the total income tax withheld during the year. Any IMRF disability payments you receive will be subject to federal income tax, but not to Illinois state income tax. If you are a resident of another state, please check with your state’s Department of Revenue to learn whether you will pay that state’s income tax on IMRF disability benefits.

If you are totally and permanently disabled, you may be eligible for a tax credit. For additional information about the tax

credit, you can contact a tax advisor or call 1-800-TAX-FORM

(1-800-829-3676) and request IRS publication 524 “Credit for the Elderly or the Disabled;” this IRS publication may be downloaded at www.irs.gov.

FILING GUIDELINES

•Do not file this claim if you are still working.

•If you will be disabled due to a planned event (e.g., elective surgery, pregnancy), submit this form after your last day at work.

•You should file this application if you expect to be disabled for more than 30 days.

•File this form even if you plan to file a workers’ compensation and/or occupational disease claim.

ATTACHMENT GUIDELINES

•A copy of your birth certificate should be filed with this application. If that document is delayed, file this application without it.

•Please print your Social Security number on all documents you enclose with this form.

IF YOU RETURN TO WORK ON A PART-TIME BASIS

• Refer to “Trial Work Period” in the IMRF Disability Benefits booklet.