top of page

Rules & fOrms

To download the following documents, click on the icon to the left.

DP Fire Pension Board Rules (Updated 12/2019)
Freedom of Information Act (FOIA) Disclosures
Application for Membership
Background Information Form
Physician's Certification Regarding Entry Level Physical Condition
Affidavit of Continued Eligibility
Affidavid of Eligibility Disability Pension Annual Examination
Authorization to Disclose Protected Health Information
Physician's Certification of Disability
Physician's Recertification of Disability
Change of Data/Records
Maintenance of Pension After Separation of Service
Application for Retirement Pension Benefits
Estimate for Retirement Pension Benefit
Application for Disability Benefits
Application for Widow/Widower and/or Dependent Benefits
Initial Request/Inquiry as to Reciprocity (Combine Article 4 Service),
Military Service Purchases, Article 4 Service Transwers,
and/or Retirement Pension Benefit Estimates
Election to Purchase Military Service Served Prior to Employment
Initial Inquiry for Costs to Combine Creditable Service
Request for Conversion Calculation
Application for Conversation of Disability Pension to Retirement Pension
Qualified Illinois Domestic Relations Order (QILDRO)
QILDRO Calculation Order
Consent to Issuance of QILDRO
Request for Certified Statement of Accumulated Contributions, Accrued Benefits and Other Interests
Statement of Financial Interest in Response to QLIDRO for Payment of a Percentage of a Retirement Benefit (Before)
Statement of Financial Interest in Response to QILDRO for Payment of a Percentage of a Retirement Benefit (After)
Consent of Alternative Payee to Retirement Benefit Election that Diminishes Payment to Alternate Payee
Application for Termination of Disability Benefits
Application for Refund of Contributions
Creditable Service Claim Form and Affidavit
Request for Calculation for Potential Transfer of Creditable Service Per
P.A.100-0544 (HB0688) From Article 4 to Article 6 (Chicago)
bottom of page