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Maine Public Employees Retirement System
P.O. Box 349, Augusta, ME 04332-0349
toll free: (800) 451-9800 ● local: (207) 512-3100

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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.
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
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
DC-0482 2016 Annual Statement of Compensation 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
 
+ 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.

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Information contained on this Web site is neither a legal reference nor a complete statement of the laws or MainePERS administrative rules. In any conflict between this information and Maine laws or administrative rules, the laws and administrative rules shall prevail.

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