Forms

General

• Form 1, Membership Application
• Form 1B, Beneficiary Designation
• Form 1C, Change of Information
• Form 4A, Non-Covered Employment Acknowledgement
• Form 5B, Spousal Waiver of Monthly Benefits
• Form NOA, Notice of Appeal
• Form PIR, Public Information Request
• Form RPR, Representative Payee Request
• Form SI, Successor Information
• Form 16, Advanced Application - Contact PERS for an Estimate of Benefits to determine whether you are eligible to file an Advanced Application.

Refund Applicants

Choose the forms packet below that is applicable to your situation then complete and submit all forms in that packet.




Active Member Refund - Direct Payment Distribution

• Form 5, Membership Refund Application




Inactive Member Refund - Direct Payment Distribution

• Form 5, Membership Refund Application
• Notary Public Acknowledgement
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Active Member Refund - Direct Payment Distribution and Request to Waive Waiting Period Due to Hardship​


• Form 5, Membership Refund Application
• Form 5W, Request to Waive Refund Waiting Period




Inactive Member Refund - Direct Payment Distribution and Request to Waive Waiting Period Due to Hardship​​

• Form 5, Membership Refund Application
• Form 5W, Request to Waive Refund Waiting Period
• Notary Public Acknowledgement




Active Member Refund - Rollover Payment Distribution


• Form 5, Membership Refund Application
• Form 5C, Rollover Distribution Election​




Inactive Member Refund - Rollover Payment Distribution


• Form 5, Membership Refund Application
• Form 5C, Rollover Distribution Election​
• Notary Public Acknowledgement




Refund Due to Member's Death - Direct Payment Distribution


• Form 5D, Beneficiary Refund Application




Refund Due to Member's Death - Rollover Payment Distribution

• Form 5D, Beneficiary Refund Application
• Form 5C, Rollover Distribution Election​




Beneficiary Waiver of Refund Due to Member's Death


• BW, Beneficiary Waiver
• Notary Public Acknowledgement




Member Waiver of Monthly Benefits in Lieu of Refund


• Form 5A, Member Waiver of Monthly Benefits

Purchase of Service Credit

• Form 12, Payment/Purchase Acknowledgement
• Refund Payback Cost Fact Sheet
  
• Form 19, Out-of-State Public Employment Certification
• Form 25A, Acknowledgement of Veteran’s Right to Purchase Service Credit
• Form 25D, Determination of Entitlement to Purchase Pension Service Credit under the Veteran’s Reemployment Rights Laws
• Form 25M, Statement of Qualified Military Service
• 
  

Service Retirement Applicants

• PERS Service Retirement Guide

PHASE 1 - Refer to PERS Service Retirement Guide

• Form 9A SRVC, Pre-Application for Service Retirement Benefits - This form must be submitted to initiate a claim for service retirement benefits.

PHASE 2 - Refer to PERS Service Retirement Guide

PERS will mail additional forms necessary for completing the service retirement application after receipt of the completed Form 9A SRVC.​​​​​​​​​​​​

Disability Retirement Applicants

• PERS Disability Retirement Guide

PHASE 1 - Refer to PERS Disability Retirement Guide
All six forms below must be submitted to initiate a claim for disability retirement benefits.

• DSBL 1, Pre-Application for Disability Retirement Benefits
• DSBL 2, Employer's Certification of Job Requirements
• DSBL 3, Employer's Job Activities Checklist
• DSBL 4, Medical Information and Prior Claim History
• DSBL 5, Physician and Treating Facility History
• DSBL 6, Family Information

PHASE 2 - Refer to PERS Disability Retirement Guide
PERS will mail additional forms necessary for completing the disability retirement application after receipt of the completed forms DSBL 1 through DSBL 6.

Survivor Retirement Applicants

• PERS Survivor Retirement Guide

PHASE 1 - Refer to PERS Survivor Retirement Guide

• Form 9A SRVR, Pre-Application for Survivor Retirement Benefits

PHASE 2 - Refer to PERS Survivor Retirement Guide

PERS will mail additional forms necessary for completing the survivor retirement application after receipt of the completed Form 9A SRVR.​

Retirees

• Form 4B,​ Reemployment of PERS Service Retiree
• Form 9C, County/Municipal Elected Official Reemployment Acknowledgement/Election
• Form 17,Certificate of Withholding Preference
• Form 20, Election for Monthly Cost-of-Living Adjustment
• Form 21, Direct Deposit Authorization
• Form 22, Waiver of Benefits
• Form R, Application for Recalculation of Benefits
• Form EVI, Employee vs. Independent Contractor Determination
• Form PV, Payment Voucher

Employers

• Form 8P, Employer Pre-Arranged Payment Authorization
• Form 10, Report of Adjustments
• Employer Guide to Certifying Leave to PERS
• Form 18, Employer Certification of Termination and Accumulated Unused Leave
• Form ERMI, Employer Request for Member Information
• MyPERS Reporting User Authorization