Rules and Forms

Des Plaines Fire Pension Board Rules (Updated 2/09)

Freedom of Information Act (FOIA) Disclosures

Form A - Application for New Membership

Form B - Background Information Form

Form C - Physician's Certification Regarding Entry Level Physical Condition

Form D1 - Affidavit of Eligibility (Retirement or Survivor's Benefits)

Form D2 - Affidavit of Eligibility (Disability Benefits)

Form E - Authorization for Release of Medical Records

Form F - Physician's Certification of Continuance of Disability

Form G - Certification of Medical Records

Form H - Change of Records

Form I - Application for Refund

Form J - Maintenance of Pension After Separation From Service

Form K - Application for Retirement Benefits

Form L - Application for Disability Benefits

Form M - Application for Widow/Widower and/or Dependent Benefits

Form N - Physician's Certification of Disability

Form O - Physician's Certification of Disability for Occupational Disease

Form P - Qualified Illinois Domestic Relations Order

Form P1 - Qildro Calculation Court Order

Form Q - Consent to Issuance of Qildro

Form Q1 - Request for Certified Statement of Accumulated Contributions, Accrued Benefits and Other Interests

Form Q2 - Statement of Financial Interest in Response to Qildro for Payment of a Percentage of a Retirement Benefit (Before)

Form Q3 - Statement of Financial Interest in Response to Qildro for Payment of a Percentage of a Retirement Benefit (After)

Form Q4 - Consent of Alternate Payee to Retirement Benefit Election that Diminishes Payment to Alternate Payee

Form R - Application for Termination of Disability Benefits

Form S - Application for Conversion of Disability Pension to Retirement Pension

Form T - Creditable Service Claim Form and Affidavit

Form U - Notice and Verification Request for Creditable Service

Form V - Application for Retirement Benefits - Former Employee

Form W - Application for Repayment of Refund or Payment for IMRF Service Credit

Form X - Notice and Verification Request for Transfer of Creditable Service from IMRF

Form Y - Change in Benefit Information Request Form

Form Z - Subpoena Form

Form Z - Subpoena Form (Duplicate)

Form AA - Official Ballot

Form BB - Request for Hearing/ Miscellaneous Issue

Form CC - Application for Establishment of Creditable Service After Return to Active Service

Form DD - Electronic Attendance Request

City of Des Plaines Fire Pension Fund

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