APPLICATION FOR DISABILITY BENEFITS
CHAMPAIGN POLICE PENSION FUND



Pension Board

I am a member of the Champaign Police Department assigned to duty as _______________(Rank)

I received my probationary appointment ______________________ 19___, and I was approved for membership in the Police Pension Fund on _____________ 19___.

I am ___________ years of age and have performed police duty, as a member of the City of Champaign Police Pension fund for ____ year(s) ______ month(s) __________ day(s).

I hereby make application for disability pension from the Police Pension Fund as of __________19___ under Section ___________ of the Pension Code.

My last work day will be ____________20___

My family consists of: _________________________________________________(Spouse name)

_______________________________________________________________________________

________________________________________________(Natural or Adopted Children Name(s))

The nature of my disability is (please be specific as to time, date and location of cause of disability):

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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The nature of the disability is (please check one):
____ in the line of duty (40 ILCS 5/4-110)
____ not in the line of duty (40 ILCS 5/4-111)
____ occupational disease disability (40 ILCS 5/4-110.1)

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Signature of Petitioner
_____________________________________
Address
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Date 		_____________________________________
Print Name
_____________________________________
City, State & Zip Code
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Phone Number