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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.

New: A number of forms are now also available for completion online with your digital signature. We refer to these forms as “Digital Signature Forms.” You do not need to print paper to fill out and submit “Digital Signature Forms.” You do not need to print paper to fill out and submit “Digital Signature Forms.” You will have an option to save an electronic copy of any form you opt to fill out electronically and sign digitally.

The Digital Signature Forms are being made available through “Carahsoft OBO Maine Public Employees Retirement System (MainePERS)” using the DocuSign Platform. These forms are located in the table below.

To select and complete an available digital signature form, click on the link in the box under the “Digital Signature Forms” column for that form. Step-by-step directions are available within the form signing process itself.

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.

Form NumberForm NameDownload form as PDFRequest form via emailDigital Signature Forms
ASC PackageAnnual Statement of Compensation Information PackageDownload PackageRequest Annual Statement of Compensation Information PackageDownload DocuSign Annual Statement of Compensation
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-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-04822021 Annual Statement of CompensationDownload DC-0482Request DC-0482
DC-0603Consent Form Authorizing Release of InformationDownload DC-0603Request DC-0603

DC-0608Application for Disability Retirement Healthcare Provider AssessmentDownload DC-0608



Request DC-0608
FS1120Earnings Limitations for Disability Retirement RecipientsDownload FS1120Request DC-0603