Disability Forms

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Forms - Disability

Forms may be downloaded by clicking the corresponding form number below. The "Request Forms"
e-mail is for ordering hardcopy forms only. Please supply your name and mailing address in the email. For all other inquiries, please contact MainePERS directly.

To use these forms you will need Adobe Reader^®. If you don't have Reader, you can get it free by clicking here.

New Applicant:
Application⁺	Application for Disability Retirement Benefits Package	Request Form

Current Recipient:
As a disability benefit recipient, you are periodically scheduled for a review to determine your continuing eligibility for these benefits. MainePERS will contact you when your review is due. The information packet and four forms below may be downloaded.		Request Packet
Packet	Review for Continuing Disability Information Packet
DC-0005⁺	Report of Continuing Disability
DC-0603A⁺	Consent Form Authorizing Release of Information
DC-0514	Medical Certification for Disability Recipients
CL-0888A⁺	Consent Form Designating Authorized Representatives

DC-0003a⁺	Addendum to Application for Disability Retirement Benefits	Request Form
DC-0482	Annual Statement of Compensation for 2011	Request Form
ASC Packet	Annual Statement of Compensation Information Packet	Request Pkt
DC-0013	Application for Survivor Benefits - CONTACT US	Request Form
DC-0013A	Addendum to Application for Survivor Benefits - CONTACT US	Request Form
CL-0875⁺	Certification of Bona Fide Termination	Request Form
DC-0603⁺	Consent Form Authorizing Release of Information	Request Form
CL-0888⁺	Consent Form Designating Authorized Representatives	Request Form
FS1120	Earnings Limitations for Disability Retirement Recipients	Request Form
DC-0008⁺	Employment Contact Form	Request Form
CL-0724	Prospective Beneficiary of Member Changing to Service Retirement	Request Form
DC-0007	Release of Information to Rehabilitation Providers	Request Form
DC-0460⁺	Termination of Employment Certification Form (Disability)	Request Form

+ Forms indicated with "+" may be viewed and completed on the screen using a recent version of Adobe^® Reader^®, printed, and mailed to the MainePERS. You may click on any line to complete that area or use TAB to move forward and SHIFT-TAB to move back. Forms cannot be saved or altered.