Disability Retirement Inquiry

What is your work status?: *

I’m currently going in to work

I’m not currently going into work (I’m out on leave, leave without pay, state disability leave, etc.)

I’m retired

Are you currently working in a lower paying job or change in position?:

Yes

No

Has your employer made a reasonable accommodation so that you can perform your job duties despite your incapacity?:

Yes

No

If Yes: Reasonable accommodations to your job duties provided by your Employer will make you ineligible for disability retirement since you are able to perform your duties. You will be eligible to apply for disability retirement if/when your department can no longer accommodate your permanent work restrictions.

Instead of disability retirement, you can begin the regular (service) retirement process if you are eligible. Please review our Preparing to Retire page.

Stop here.

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Has a doctor deemed you PERMANENTLY incapacitated so that you cannot perform one or more of your job duties?: *

Yes

No

If no, you are not eligible to apply for disability retirement at this time. You must be deemed permanently incapacitated by a medical doctor from performing your regular and customary job duties in order to apply for disability retirement. You can apply for regular (service) retirement if you are eligible. We recommend reviewing the eligibility requirements for regular (service) retirement.

Stop here.

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Is your permanent incapacity/disability connected to your employment?: *

Yes, my incapacity/disability is the result of an injury or a disease arising out of and in the course of my employment, and my employment contributed substantially to my incapacity.

No. I’m permanently incapacitated/disabled, but my employment did not substantially contribute to my injury/illness.

If yes, please continue completing the form.

Do you have at least 5 years of service credit with ACERA?:

Yes

No

If yes, please continue completing the form.

You must have at least 5 years of service credit with ACERA to apply for a non-service connected disability retirement. Purchasing eligible time as service credit will count towards the 5 years needed, so you may review our page on Purchasing and Redepositing Service Credit.

Stop here and come back to this form after you’ve made your service credit purchase to get above the 5-year requirement.

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I will be able to provide the documentation listed below with my disability retirement application.: *

Yes

No

Medical documentation demonstrating my permanent incapacity
(For service connected disability retirement only) Documentation demonstrating that my employment contributed substantially to my disability, and that my injury/illness prevents me from performing my regularly assigned job duties

This documentation will be a requirement of the disability retirement application. If you anticipate you won’t be able to provide this documentation, you should stop here.

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Application Requirements

Please check each item below, signifying that you have read and understand that you will be required to submit each item later as part of your complete disability retirement application.

A completed application submitted to ACERA with all supporting documentation/medical records & reports. Incomplete applications will not be accepted. All questions must be answered, responses must legible and signatures executed on the application.

Medical Reports: Must be submitted with the disability retirement application. Medical documents and reports can be submitted electronically, on CD, flash drives or paper copies.

Medical Provider Statement (completed by Doctor): Must be completed by your treating physician

Essential Function Job Analysis (EFJA): This form must be obtained from your employer, reviewed and signed by your treating physician and submitted with the application.

Delayed Disability Application Affidavit (DDAA): Must be completed by the member and treating physician if more than four months have elapsed from the last day in service (last day pensionable compensation received). Treating physician must state that the member has been permanently incapacitated physically or mentally from performing their usual and customary job duties since the date they discontinued service.

Disability Retirement Handbook: You must review the application process in the Disability Retirement Handbook.

Disability Retirement Handbook

You must file your complete application (with all the items in the previous question above) within one of the following 3 time periods. Select which time period you plan on submitting your disability retirement application.: *

While I am in service (I am receiving compensation from which retirement contributions are deducted)

Within 4 months after the date the I will last receive compensation from which retirement contributions will be deducted

At any time after the discontinuation of service (even past the initial 4 months), if I establish that I was continuously permanently incapacitated from the discontinuation of service

Other time period

You must submit a complete retirement disability application during one of the three time periods listed. If you cannot meet the requirements, you should consider not submitting an application.

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I understand the disability retirement application process can take 6-9 months on average depending on whether additional evidence, further examinations or a hearing is requested.: *

Yes

Are you also interested in applying for regular (service) retirement?: *

Yes

No

If yes, you may apply for regular (service) retirement at any time you are eligible including before, after, or at the same time you apply for disability retirement. Please note that if you retire with a regular (service) retirement and your disability retirement application is denied approval by the Board of Retirement, you cannot return to work. This is because regular (service) retirement is a permanent termination of your employment.

Members who retire with regular (service) retirement while their disability application is pending may change their retirement payment option if they are awarded a disability retirement.

If you are still interested in disability retirement, please continue completing this form. For more information on applying for regular retirement, visit our Applying to Retire page.

First Name: *

Middle Name or Initial :

Last Name: *

Date of Birth: *

Personal Email Address: *

Mobile Phone Number: *

Work Phone Number:

Current Mailing Address: *

Current Marital, State-Registered Domestic Partnership, or Alameda County Domestic Partnership Status: *

Married or Partnered

Divorced or Partnership Dissolved

Single & Never Married or Partnered

Spouse or Domestic Partner Deceased

First Name of Spouse, State-Registered Domestic Partner, or Alameda County Domestic Partner:

Last Name of Spouse, State-Registered Domestic Partner, or Alameda County Domestic Partner:

Date of Birth of Your Spouse, State-Registered Domestic Partner, or Alameda County Domestic Partner:

Have you ever divorced or dissolved your state-registered domestic partnership before or during your ACERA membership?: *

Yes

No

If yes, you should do 2 things after you submit this form:

Review the information on our divorce page.
Provide the documents to ACERA that are outlined on the divorce page, if you haven’t already done so.

Do you have reciprocity with one or more other public retirement systems?: *

Yes

No

If yes, please submit a disability retirement application with all the linked reciprocal systems.

List reciprocal systems:

If you’re approved to proceed with a disability application, how would you like to receive the disability application packet?: *

Email (Preferred)

U.S. Mail

How would you like to meet with ACERA staff regarding your potential disability retirement application?: *

Phone call

Zoom video call where you can see the counselor and they can share their screen with you so you can follow along

In-person office appointment (limited availability)

In-person office appointments are reserved for those who are unable to meet over phone or Zoom. If you are able to meet in either of those ways, we ask that you select phone or Zoom. More information here.

Please state your second choice of counseling session type if no in-person appointments are available due to their limited availability.: *

Phone call

Zoom video call where you can see the counselor and they can share their screen with you so you can follow along

I hereby request a disability application be sent to me.

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