| Application Type |
Triggering Question |
Document Type |
Association |
Instructions |
|
| Disability Part A |
In which capacity are you filling this application? If Authorized Representative: |
<Letter of Representation> |
<Authorized Representative> |
Provide a letter of representation stating that the authorized representative has the authority to act on the claimant’s behalf. |
|
| Has a final determination been issued for any of the following? If Medical Retirement/Disability: |
Other Benefits |
Medical Retirement/ Disability Decision |
The Medical Retirement/Disability Decision is an evidentiary document certifying that a final decision has been rendered on a Medical Retirement/Disability claim. |
|
| Has a final determination been issued for any of the following? If Workers’ Compensation: |
Other Benefits |
Workers’ Compensation Decision |
The Workers’ Compensation final decision is an evidentiary document certifying that a decision has been rendered on a Workers’ Compensation claim. |
|
| Has a final determination been issued for any of the following? If Social Security: |
Other Benefits |
Social Security Decision |
The Social Security Decision is an evidentiary document certifying that a final decision has been rendered on a Social Security claim. |
|
| Has a final determination been issued for any of the following? If Federal Employees' Compensation Act: |
Other Benefits |
Federal Employees' Compensation Act Decision |
The Federal Employees' Compensation Act (FECA) final decision is an evidentiary document certifying that a decision has been rendered on a FECA claim. |
|
| Has a final determination been issued for any of the following? If D.C. Retirement and Disability Act: |
Other Benefits |
DC Retirement and Disability Act Decision |
The DC Retirement and Disability Act final decision is an evidentiary document certifying that a decision has been rendered on a DC Retirement and Disability claim. |
|
| Has a final determination been issued for any of the following? If September 11th Victim Compensation Fund: |
Other Benefits |
September 11th Victim Compensation Fund Decision |
The September 11th Victim Compensation Fund (VCF) final decision is an evidentiary document certifying that a decision has been rendered on a September 11th VCF claim. |
|
| Has the Officer worked at any job following the injuries? If Yes or No: |
Tax Returns |
<Public Safety Officer> |
Provide state, local, and federal tax returns filed by or on behalf of the Public Safety Officer from the year before the injury to the current year. If the Public Safety Officer filed jointly with their spouse, provide W2s for both individuals from the year before the injury to the current year. |
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