Disability Forms

Forms may be downloaded by clicking the download links below. To request a hardcopy form, 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®.  Information on completing forms with Reader®.  Forms using Adobe Reader can be printed, but cannot be saved electronically.

Digital Signature Forms through DocuSign: A number of forms are available for completion online with your digital signature and these forms are identified in the “Digital Signature Forms” column next to the form name. The form is completed, signed, and submitted electronically. You will have an option to save an electronic copy of any form you opt to fill out electronically and sign digitally.

Once you select the document, step-by-step directions are available within the DocuSign application.

Click here for more information on digital signatures

Digital Signature:

A digital signature means a computer-created electronic signature that is:

  • intended by the person using it to have the same force and effect as the use of a manual signature;
  • unique to the person using it;
  • capable of verification;
  • under the sole control of the person using it; and
  • linked to data in such a manner that it is invalidated if changes are made to the data.

Digital signatures require creation by specialized software platforms.

Disability Applicant Forms & Brochure

Form NumberForm NameDownload form as PDFRequest form via emailDigital Signature Forms
DC-0003aAddendum to Application for Disability Retirement BenefitsDownload DC-0003aRequest DC-0003a
Brochure NameDownload brochure as PDFRequest brochure via email
Qualifying for Disability RetirementDownload Qualifying for Disability Retirement BrochureRequest Qualifying for Disability Retirement Brochure

Consent, Release of Information, and Provider Assessement Forms

Form NumberForm NameDownload form as PDFRequest form via emailDigital Signature Forms
CL-0888Consent Form Designating Authorized RepresentativesDownload CL-0888Request CL-0888
CL-0888AConsent Form Designating Authorized RepresentativesDownload CL-0888An/a
DC-0603Consent Form Authorizing Release of InformationDownload DC-0603Request DC-0603
DC-0608Application for Disability Retirement Healthcare Provider AssessmentDownload DC-0608Request DC-0608

Disability Retiree Forms

Form NumberForm NameDownload form as PDFRequest form via emailDigital Signature Forms
ASC PackageAnnual Statement of Compensation Information PackageDownload Annual Statement of Compensation Information PackageRequest Annual Statement of Compensation Information PackageDownload DocuSign Annual Statement of Compensation Information Package
Review PackageReview for Continuing Disability Information PackageDownload Review for Continuing Disability Information Packagen/a
DC-0008Employment Contact FormDownload DC-0008Request DC-0008
DC-04822024 Annual Statement of CompensationDownload DC-0482Request DC-0482
DC-0609Annual Statement of Compensation (ASC) Waiver Request FormDownload DC-0609Request DC-0609
FS1120Earnings Limitations for Disability Retirement RecipientsDownload FS1120Request FS1120

Federal and State Withholding Forms

Form NumberForm NameDownload form as PDFRequest form via email
W-4PIRS-Withholding Certificate for Pension or Annuity PaymentsDownload W-4P

W-4MEState of Maine - Employees Withholding Allowance CertificateDownload W-4ME
CL-0905Non-Resident Certification for Maine Tax WithholdingDownload CL-0905


Request CL-0905
W-4RIRS-Withholding Certificate Nonperiodic Payments and Eligible Rollover Distributions. (This tax form is for Refunds and Rollover payments.)Download W-4R