APPLICATION FOR SURVIVORS PENSION
CHAMPAIGN POLICE PENSION FUND
Date _______________
I,______________________________________________________ hereby make application for a survivor’s pension from the Champaign Police Pension Fund.
Survivor’s date of birth _______________
Date of marriage _______________
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Current mailing address
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Date of death of police officer ___________________
Name of deceased police officer __________________________________________
Survivor’s social security number _____________________________
Signature_____________________________________________________
Approved:
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