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
www.dcrb.dc.gov
Request for Information from Retirement File
Please complete this form to request information from your Retirement File with the District of Columbia Retirement Board
(DCRB). Upon receipt of your request, DCRB will respond within ten (10) to twenty (20) business days depending on the re-
quest. Some requests may take longer. You may also be asked to provide additional identification information for verification
purposes. DCRB has discretion to charge a fee for producing certain copies.
Section I: Member Information
Name: ______________________________________________________ Date of Birth: ____________________
(Please print your full name.)
Employee ID or Social Security Number: __________________________ Phone Number: _____-_____-______
Mailing Address: __________________________________________________________________________________
Street City State Zip Code
Email: ___________________________________________________________________________________________
Retirement Plan: Police Officer/Firefighter Teacher
Section II: Individual to Whom Information May be Released (if other than the Member)
Name: ________________________________________________Relationship to Member:____________________
Mailing Address: __________________________________________________________________________________
Street City State Zip Code
Email: ___________________________________________________________________________________________
Section III: Request
Reason for Request: ________________________________________________________________________________
_________________________________________________________________________________________________
Specific Information Requested: _____________________________________________________________________
_________________________________________________________________________________________________
Section IV: Authorization
I authorize the District of Columbia Retirement Board (DCRB) to release the information from my Retirement File as indicated
above. I acknowledge that I understand the purpose of this request, that fees may apply, and that authorization is hereby grant-
ed voluntarily
Member Signature: _______________________________________________ Date: ___________________________
DCRBFormRI-300 Revised 06/2015
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