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Statement of Disability and Medical Release

About this Form

Form number: 455-24

Audience:  MCPS Staff

Last revised: November 2011

Related Forms

Form 455-25 - Attending Physician's Statement

Form 455-2A - Request for Estimate of Retirement Benefits

INSTRUCTIONS: To be completed by an employee applying for disability retirement.

Adobe PDF Statement of Disability and Medical Release82 KEnglish

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