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Preliminary Application for Disabiity Benefit

About this Form

Form number: 455-23

Audience:  MCPS Staff

Last revised: November 2011

INSTRUCTIONS: To be completed by an employee applying for disability retirement.

Purpose: The purpose of filing a Preliminary Application for Disability Retirement is to protect the benefit payable by Montgomery County Public Schools to the beneficiary designated below, if you are granted a disability retirement allowance but die during the Applicable Period as defined below. If you die after the expiration of the Applicable Period, the application shall have no force and effect and no benefits shall be payable under this Application.

Definition: When used in the form, the term “Applicable Period” means the period that begins on the date that I submit a completed Preliminary Application for Disability Retirement to MCPS and ends on the retirement date that I select on a completed Application for Retirement (MCPS 455-2).

Adobe PDF Preliminary Application for Disabiity Benefit89 KEnglish

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