Call us toll free: (800) 451-9800 | local: (207) 512-3100 | P.O. Box 349, Augusta, ME 04332

Change text size

Disability Forms

Forms may be downloaded by clicking the download links below. To request hardcopy forms, please send an email request via the link in the “Request form via email” column next to the form name. 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 the Adobe link above. For information on completing forms with Reader® click here.

Forms cannot be saved or altered.

Form NumberForm NameDownload form as PDFRequest form via email
ASC PackageAnnual Statement of Compensation Information PackageDownload PackageRequest Annual Statement of Compensation Information Package
Review PackageReview for Continuing Disability Information PackageDownload Review for Continuing Disability Information Packagen/a
CL-0724Prospective Beneficiary of Member Changing to Service RetirementDownload CL-0724Request CL-0724
CL-0875Certification of Bona Fide TerminationDownload CL-0875Request CL-0875
CL-0888Consent Form Designating Authorized RepresentativesDownload CL-0888Request CL-0888
CL-0888AConsent Form Designating Authorized RepresentativesDownload CL-0888An/a
DC-0003aAddendum to Application for Disability Retirement BenefitsDownload DC-0003aRequest DC-0003a
DC-0005Report of Continuing DisabilityDownload DC-005n/a
DC-0007Release of Information to Rehabilitation ProvidersDownload DC-0007Request DC-0007
DC-0008Employment Contact FormDownload DC-0008Request DC-0008
DC-0013SApplication for Survivor BenefitsDownload DC-0013S SAMPLERequest DC-0013s
DC-0013AAddendum to Application for Survivor BenefitsDownload DC-0013A SAMPLERequest DC-0013A
DC-04822019 Annual Statement of CompensationDownload DC-0482Request DC-0482
DC-0514Medical Certification for Disability RecipientsDownload DC-0514n/a
DC-0603Consent Form Authorizing Release of InformationDownload DC-0603Request DC-0603
DC-0603AConsent Form Authorizing Release of InformationDownload DC-0603An/a
FS1120Earnings Limitations for Disability Retirement RecipientsDownload FS1120Request DC-0603