District of Columbia Retirement Board (DCRB)
Benefits Department
900 7th Street, NW, 2nd Floor Washington, DC 20001
Telephone: (202) 343-3272 Toll Free: (866) 456-3272 Fax: (202) 566-5001
Contribution Balance Request Form
Requests for your contribution balance with the District of Columbia Retirement Board (DCRB) must be made in writing by com-
pleting this form. Upon receipt of this request, DCRB will respond to your request within ten (10) business days. Some situa-
tions may result in a longer time period if necessary. You will be contacted if this situation arises.
Section I: Member Information
Name: Mr. Mrs. Miss Ms.
Last Name
First Name Middle Initial
Date of Birth: _________________________________ Social Security Number: _______________________________
Mailing Address: __________________________________________________________________________________
Street City State Zip Code
Email: ______________________________________________ Phone Number: __________-___________-__________
Plan Status (select one): Non-Active Plan Member (Terminated Vested) Active Employee Member*
*If you select “Active Employee Member,” you will need to contact the District of Columbia’s Office of Pay and Retirement Ser-
vices at 202-741-8660 to receive your contribution balance. Please do not submit this form to DCRB
Retirement Plan (select one) : Police Firefighters’ Teachers
Section II: Service Dates
Date of Hire: ______/______/______ Date of Separation/Termination: ______/______/______
Section III: Purchase of Service Information (if applicable)
Did you purchase any additional service ? Yes No 
If “Yes,” when was the completion date of your purchase of service ? ______/______/______
Section IV: Authorization
I authorize the District of Columbia Retirement Board (DCRB) to release the contribution balance information to me as indicat-
ed above. I acknowledge that I understand the purpose of this request and that authorization is hereby granted voluntarily.
Member Signature: _______________________________________________ Date: ___________________________
Revised 7/2014
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