Your completed form must be received by DCRB prior to the 15th of the month to allow for processing for the following month. The form must be completed in its entirety or processing may be delayed.

Please provide a copy of your unexpired ID or passport when submitting this form for processing.

Your mailing address (home address if same) is the address where your monthly annuity earnings statement and annual IRS 1099-R form of your pension distribution will be mailed.

Note: If you are completing and submitting this form as the Payee’s authorized representative, your representation must have been approved acceptable by DCRB. If your representation has not been approved by DCRB, you must include a copy of a valid Power of Attorney or a certified copy of the appropriate court order.