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Form: Report of Employer for Disability Applicant
The form made available on this page is provided in its most recent version and is available to view or print in a PDF format PDF. If you have trouble viewing or printing the form, then please consult the help page for assistance. To order this form, please visit the form order page for instructions.
Form Name Report of Employer for Disability Applicant PDF
Form Code DR-4
Last Revised Date 04/2014
Next Revision Date None expected at this time
This form is used to compile information from the applicant’s most recent public employer. Specifically, it seeks information about the applicant’s job title and duties, final date of compensation and retirement deductions.
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