What is Standard Form 3112A?

Standard Form (SF) 3112A is entitled “Applicant’s Statement of Disability” and is contained in SF 3112: “Documentation in Support of Disability Retirement Application.” You, the applicant, are responsible for completing this form (and you must provide a copy to your supervisor in order for your supervisor to be able to complete SF 3112B: “Supervisor’s Statement”). Take the time to describe your medical conditions in detail. Note that you are required to explain how your medical conditions directly prevent you from performing one or more of the essential functions of your job. In addition, you are required to explain the adverse impact of your medical conditions on your personal life and daily activities. Don’t forget to attach your Social Security Disability application receipt, and don’t forget to sign and date the “Applicant’s Consent and Certification.”