This form is used to report the death of a retiree or survivor annuitant who is currently receiving or who may be entitled to a benefit under the District of Columbia Police Officers', Firefighters', and Teachers' Retirement Plans (the Plan or Plans). Life events, such as a death, can affect benefits and should be reported immediately.

Note: All payments received from DCRB after the annuitant's date of death must be returned. If the payment is made by check, please write the date of death on the check, and return the check to the address on the envelope. If payments are made by direct deposit, please inform the financial institution of the death.