This form is valid only for survivors of Police Officers or Firefighters who were enrolled in the District of Columbia Police Officers and Firefighters' Retirement Plan. 
In accordance with D.C. Code §§5-716(e)(1), 5-716(e)(2), and 5-723(a), survivor annuity payments of deceased survivor annuitants are to be prorated for the number of days the deceased survivor had lived during the month and are to be paid under the order of precedence set forth in D.C. Code §5-723(d).

You can send the completed form and any required attachments by fax to (202) 566 -5001 or by mailing your documents to:

DC Retirement Board
Member Services Center
900 7th Street, NW, Second Floor
Washington, DC 20001

If you have further questions, please contact the DCRB Member Services Center by clicking on the Ask Member Services link, or by phone at (202) 343-3272 Monday – Friday from 8:30 am to 5:00 pm.