Forms

All PERS forms are available for print, to download, or to have mailed to you. Please follow the instructions on this page to access the forms in the manner most convenient to you. Please note that all forms on this page are the most current version; so, if you have previously printed, downloaded, or received a PERS form, please reference the revision date on each form below to ensure you are using the most current version.

To Print and/or Download Forms

Click on any form name below to view it in PDF format. From that screen, you may either send the form to print or save the form to your computer. These PDFs are interactive, which provides you with the option to complete certain sections digitally. When using Safari, Chrome, or Firefox, PERS recommends downloading each desired form for the purpose of filling in and/or printing.

To Have Forms Mailed to You

To have PERS mail you a form, fill out the contact information below and then select the box to the left of your desired form. You may check as many boxes as needed.

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    • General

    Form 1, Membership Application
    Form 1B, Beneficiary Designation
    Form 1C, Change of Information
    Form 4A, Non-Covered Employment Acknowledge
    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 a Form 16, 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

    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
    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 toPERS Service Retirement Guide

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

    PHASE 2 - Refer toPERS 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 toPERS 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 toPERS Disability Retirement Guide

    PERS will mail additional forms necessary for completing the disability retirement application after recepit of the completed forms DSBL 1 through DSBL 6.

    Survivor Retirement Applicants

    PERS Survivor Retirement Guide

    PHASE 1 - Refer toPERS Survivor Retirement Guide

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

    PHASE 2 - Refer toPERS 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 Accumlated Unused Leave
    Form ERMI, Employer Request for Member Information
    MyPERS Reporting User Authorization

    IRS Forms

    These forms belong to the Internal Revenue Service and are to be used with the following PERS forms: R, 17, 14, DSBL 10, 9P, PLSO, 5, 5C, and 5D.