APPLICATION FOR RETIREMENT BENEFITS
CHAMPAIGN POLICE PENSION FUND
Office Phone (217) 359 - 4827



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 retirement pension from the Police Pension Fund as of __________19___.


My last work day will be ____________20___

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