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Form 1, Membership Application (revised 08/01/12)
Form 1B, Beneficiary Designation (revised 08/01/12)
Form 1C, Change of Information (revised 08/01/12)
Form 4A, Non-Covered Employment Acknowledgment (revised 08/01/12)
Form 9A SRVR, Pre-Application for Survivor Retirement Benefits (revised 02/21/13)
Form 16, Advanced Application (revised 05/17/13)
Contact PERS for an Estimate of Benefits to determine whether you are eligible to file an Advanced Application.
NOA, Notice of Appeal (revised 11/27/12)
PIR, Public Information Request (revised 06/11/12)
RPR, Representative Payee Request (revised 03/28/13)
Form 5, Member Refund Application (revised 10/30/12)
Form 5A, Member Waiver of Monthly Benefits (revised 10/01/12)
Form 5B, Spousal Waiver of Monthly Benefits (revised 10/01/12)
Form 5C, Rollover Distribution Election (revised 10/01/12)
Form 5D, Beneficiary Refund Application (revised 10/30/12)
Form 5W, Request to Waive Refund Waiting Period (revised 10/01/12)
Form 12, Payment/Purchase Acknowledgement (revised 12/01/12)
Form 19, Out-of-State Public Employment Certification (revised 04/02/13)
Form 25A, Acknowledgement of Veteran’s Right to Purchase Service Credit (revised 04/17/13)
Form 25D, Determination of Entitlement to Purchase Pension Service Credit under the Veteran’s Reemployment Rights Laws (revised 04/17/13)
Form 25M, Statement of Qualified Military Service (revised 04/17/13)
SRVC Guide, PERS Service Retirement Guide (created 04/10/13)
Form 9A SRVC, Pre-Application for Service Retirement Benefits (revised 04/23/13)
PERS will mail additional forms necessary for completing the service retirement application after receipt of the completed Form 9A.
DSBL Guide, PERS Disability Retirement Guide (created 03/13/13)
All six forms below must be submitted to initiate a claim for disability retirement benefits.
DSBL 1, Pre-Application for Disability Retirement Benefits (revised 12/11/12)
DSBL 2, Employer’s Certification of Job Requirements (revised 12/11/12)
DSBL 3, Employer’s Job Activities Checklist (revised 12/11/12)
DSBL 4, Medical Information and Prior Claim History (revised 12/11/12)
DSBL 5, Physician and Treating Facility History (revised 12/11/12)
DSBL 6, Family Information (revised 12/11/12)
Form 4B, Reemployment of PERS Service Retiree Certification/Acknowledgement (revised 08/01/12)
Form 9C, County/Municipal Elected Official Reemployment Acknowledgement/Election (revised 02/21/13)
Form 17, Certificate of Withholding Preference (revised 04/30/13)
Form 20, Election for Monthly Cost-of-Living Adjustment (revised 04/30/13)
Form 21, Direct Deposit Authorization (revised 08/16/12)
Form R, Application for Recalculation of Benefits (revised 05/17/13)
PV , Payment Voucher (revised 04/03/13)
EIC, Employee vs. Independent Contractor Determination Questionnaire (revised 04/23/13)
Form 8P, Employer Pre-Arranged Payment Authorization (revised 04/30/13)
Form 10, Report of Adjustments (revised 05/16/13)
Form 18, Employer Certification of Termination and Accumulated Unused Leave (revised 05/16/13)
ERMI, Employer Request for Member Information (revised 08/01/12)
WEB-ERS, WEB-ERS Authorization (revised 05/16/13)
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