Skip to form
SeamlessDocs

Section I Member Information
Married
Separated Date
II
Did you receive a refund or rollover of your employee contributions when you left the Department
Plan Type
Divorced
Single
I
III 25 years
Was this amount later redeposited with the Plan prior to you reaching age 55
Do you elect to have your annuity from DCRB reduced by ten 10 percent to supplement your survivors bene
Surviving Spouse
Over18-1
Over 18_2
Over 18_3
Over 18_4
Over 18_5
Over 18_6
Surviving Child
If you are divorced is your annuity subject to the DC Spouse Equity Act of 1988 DC Code 152901 et
If you answered yes to question 3 does DCRB currently have a Qualified Domestic Relations Order QDRO
Are there any children currently listed on your health insurance
Are there any children that you provide at least fifty 50 percent of their support
Signature HereClick to Sign
03/11/2026Click to Sign
x

Additional Signatures Required

Upload Attachment(s)

Please upload the following attachments:

There is a 250MB limit on each attachment.

Attachment 1 Click Here to Upload
Attachment 2 Click Here to Upload
Attachment 3 Click Here to Upload