Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.1024, fax www.pers.ms.gov
Pre-Application for Disability Retirement Benefits
Form DSBL 1 – Revised 06/01/2018
Please print or type in black ink. Each employer must complete a separate DSBL, Pre-Application for Disability Retirement Benefits. Mail or
fax completed form(s) to PERS. See bottom of form for contact information.
Member Information – To be completed by the member or an authorized representative of the member. Attach a copy of member’s birth certificate.
First Name: _______________________________________ MI: ______ Last Name: ______________________________________ Gender: M F
Social Security No.: __________________________ Birth Date mm/dd/ccyy: ___________________ E-Mail: ____________________________________
Mailing Address: ___________________________________________ City: ___________________________ State: ________ Zip: _______________
Phone: __________________________________ Cellular Home Work Phone: ____________________________ Cellular Home Work
Disability Type: Non-Duty Related Duty Related Served active duty in U.S. Armed Forces?
If yes, attach Form(s) DD214 ........ Yes No
Retirement Plan – Select applicable plan.
Public Employees’ Retirement System of Mississippi (PERS) Mississippi Highway Safety Patrol Retirement System (MHSPRS)
Supplemental Legislative Retirement Plan (SLRP)
Potential Beneficiaries – For estimate purposes only. Please list a person only (no trust, estate, etc.). Actual beneficiaries will be selected later on Form
DSBL 9, Disability Retirement Application.
Beneficiary Name Social Security No. Birth Date mm/dd/ccyy Relationship
Options 2, 3, 4, or 4A: _________________________________________ __________________________ _____________________ ______________
Option 3 second beneficiary only: ________________________________ __________________________ _____________________ ______________
Applicant Authorization – I understand that this Pre-Application for Disability Retirement Benefits will become null and void if I do not complete and file
all required documents in the physical office of PERS within 90 days following the effective date of retirement established upon the filing of this form and that my
actual retirement date will be no earlier than the first of the month after my actual termination from employment. If an authorized representative signs this form,
attach a copy of the durable power of attorney, conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.
Applicant Signature: ____________________________________________________________________ Date mm/dd/ccyy: ________________________
Employer Certification of Member Information – To be completed by an authorized representative of the employer. Original Revised
Position Held/Job Title: __________________________________ Status (check all that apply) – Elected Official Fee Paid Official Public Safety Employee
Official Hire Date mm/dd/ccyy: ______________________________ Official Termination Date mm/dd/ccyy: ___________________________________
I hereby certify that an accident or traumatic event occurred in the performance of duty. .............................................................................................. Yes No
If yes, attach copy of Workers’ Compensation Report.
Projected Unreported Gross Earnings/Leave Payment/Accumulated Leave – Project all unreported wages from the month this application is completed
through the month the last Wage and Contribution Report will be submitted for this employee. For members who are elected officials and who will receive
Elected Official Leave, please
attach a listing of all dates of elected service and offices held.
Projected Unreported Gross Earnings
Not including leave payment.
Not including compensatory leave payments
Lawfully Accumulated Unused,
Uncompensated Leave
Projected Gross Unreported Leave Payment, if
applicable and for not more than 30 days/240 hours:
$ ________________________________________
Lump sum leave payment rate of pay:
$ _____________________ per Hour or Day
Unused, uncompensated personal and
major medical leave:
____________ Hours Days
Leave accrual rate annually at termination:
_____________ Hours Days
$ _________________________
$ _________________________
$ _________________________
Certification of Increase in Salary or Compensation – Complete only if employee’s earnings increased in excess of 8 percent annually during the 24-
month period prior to the effective date of retirement. Check all that apply.
I certify that this employee’s earnings increase was authorized: as a result of a position change, or as provided under State Personnel Board rules, or
under statutory enactment (cite Statutory Provision: _______________________), or none of the above. I certify that this salary increase was or
was not provided contingent upon a promise to retire. I understand that any person who makes a false statement or shall falsify or permit to be falsified any
record of a retirement plan administered by PERS in an attempt to defraud the plan may be subject to criminal prosecution. With that understanding, I certify
that the above information is true and correct.
Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________
Employer Representative’s Name: _______________________________________ Employer Representative’s Title: _______________________________
Employer Representative’s Phone: _________________________ Fax: _________________________ E-Mail: __________________________________
Employer Representative’s Signature: _______________________________________________________ Date mm/dd/ccyy: _______________________
