Disability Benefits Forms

Forms - Disability

Forms may be downloaded by clicking the corresponding form number below. The "Request Forms" e-mail is for ordering hardcopy forms only. 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 icon to the right.

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Application⁺	Application for Disability Retirement Benefits Package	Request Form

DC-0482⁺	Annual Statement of Compensation for 2009	Request Form
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
CL-0724	Prospective Beneficiary of Member Changing to Service Retirement	Request Form
DC-0007	Release of Information to Rehabilitation Providers	Request Form
DC-0005	Report of Continuing Disability - CONTACT US	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.