Report Of Public Safety Officers Permanent And Total Disability
ADVERTISEMENT
1
2APPROVED OMB No. 1121-0166
Expires 04/30/2007
U.S. DEPARTM ENT OF JUSTICE
FOR BJA USE ONLY
OFFICE OF JUSTICE PROGRAM S
BUREAU OF JUSTICE ASSISTANCE
PDC
PUBLIC SAFETY OFFICERS' BENEFITS PROGRAM
W ASHINGTON, D.C. 20531
CASE #
REPORT OF PUBLIC SAFETY OFFICERS'
DATE RECEIVED
PERM ANENT AND TOTAL DISABILITY
This information is being requested pursuant to the Omnibus Crime Control and Safe Streets Act of 1968, as amended (42 U.S.C. 3796) and the disclosure is voluntary. This form
will be used by the Department of Justice to determine eligibility of a permanently and totally disabled officer for the payment of benefits, and the information may be disclosed to
Federal, State, and local agencies to verify eligibility for benefits. Disclosure of an individual's Social Security number is voluntary. Failure to supply all of the requested
information may result in a delay in processing this form and the receipt of benefits. PLEASE PRINT PLAINLY OR TYPE.
1. NAME, ADDRESS, AND TELEPHONE NUMBER OF DISABLED OFFICER
2. SOCIAL SECURITY NO.
3. DATE OF BIRTH
4. DATE OF INJURY
5. STATEMENT ON OTHER CLAIMS FILED WITH THE UNITED STATES GOVERNMENT AND/OR THE DISTRICT
OF COLUMBIA: Claim has been filed for benefits under (please circle):
(1) Federal Employees Compensation Act, Section 8191 Title 5, U.S. Code?
YES
NO
(2) D.C. Retirement and Disability Act of September 1, 1916, Sec. 4-622?
YES
NO
6. NAME AND MAILING ADDRESS OF PUBLIC SAFETY AGENCY, ORGANIZATION OR UNIT IN WHOSE
SERVICE THE INJURY OCCURRED
7. NAME OF DISABLED OFFICER'S SUPERIOR OFFICER
8. TELEPHONE NO.
9. PLEASE CIRCLE OFFICER'S EMPLOYMENT STATUS WHEN INJURY OCCURRED
FULL-TIME
PART-TIME
VOLUNTEER
OTHER (Specify)
10. PLEASE CIRCLE AND ATTACH ALL APPLICABLE REPORTS RELATING TO THE DIRECT CAUSE OF THE PERMANENT AND TOTAL DISABILITY.
PROVIDE A CERTIFIED COPY OF ORIGINAL REPORTS.
DETAILED STATEMENT OF CIRCUMSTANCES
MEDICAL/HOSPITAL RECORDS
INVESTIGATION
TOXICOLOGY ANALYSIS
OTHER
O JP AD M IN FO R M 3650/7 (R ev 7/2003)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form It-140 - Schedules H & E - Certification For Permanent And Total Disability And Credit For Income Tax Paid To Another State - 2013
Financial
Schedules H & E (form It-140) - Certification For Permanent And Total Disability And Credit For Income Tax Paid To Another State - 2011
Financial
Form Sfn 24777 - Application For Senior Citizen Or Permanently And Totally Disabled Renter's Property Tax Refund - 2012
Financial
Form Sfn 27777 - Application For Senior Citizen Or Permanently And Totally Disabled Renter's Property Tax Refund - 2007
Legal
Form Sfn 24777 - Application For Senior Citizen Or Permanently And Totally Disabled Renter's Property Tax Refund - 2009
Financial
Form Sfn 24777 - Application For Senior Citizen Or Permanently And Totally Disabled Renter's Property Tax Refund - 2010
Financial
Related Categories
Parent category: Legal