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​Forms: Alphabetical Order

These forms may be viewed using the free Adobe Acrobat Reader.  These forms are also available by contacting PSERS

Name 01​Form Number​Fillable
​Agent's Acknowledgement ​PSRS-248-1
​Authorization for Direct Rollover (Retirement)​PSRS 1264
Authorization for Release of Information​PSRS 1273
Authorization for Direct Deposit - Electronic Transfer of Monthly Benefit​PSRS 116
Change of Address for PSERS Retirees​PSRS 1301
Credit for Military Service​PSRS 28
Credit for Out-of- State Service​​PSRS 278
Credit for U.S. Government Service​PSRS 600
Disability Retirement Explanation
​PSRS 123
Executor Request for PSERS Documents 
PSRS 1332
Guide to your PSERS-Issued Form 1099R (SAMPLE)​
​PSRS 293
Multiple Service Membership​PSRS 1259
Nomination of Beneficiaries​PSRS 187
Nomination of Beneficiaries Addendum​PSRS 1253
Option Designation​PSRS 631
PSERS Health Options Program​PSRS 1165
PSERS Verification of Deposit
​PSRS 1326
Purchase Credit for Cadet Nurse Service​PSRS 1128
Purchase Credit for Full-Time Service​​PSRS 27
Purchase Credit for an Approved Leave of Absence​PSRS 112
Purchase Credit for Part time Service​PSRS 100
Power of Attorney​PSRS 248
​POA Relationship Affidavit​PSRS 248-4
POA Florida Affidavit​PSRS 248-2
POA Non-Durable Affidavit​PSRS 248-3
Purchase Maternity Leave of Absence (Commencing Prior to November 1, 1978)​PSRS 1127

​Questionnaire to determine the applicant's eligibility for PSERS membership

​PSRS 349
Refund Application – Contact PSERS to acquire this form
Retirement Application for a Disability Retirement – Requires counseling. Contact PSERS to acquire this form
Return Withdrawn Contributions​PSRS 696
Request for Recalculation Estimate Due to Change in Marital Status or Death of Survivor Annuitant​PSRS 1309
Rollover Certification for Purchase of Creditable Service​PSRS 928
Release for Medical Records​PSRS 607
Request for Retirement Estimate​PSRS 151
Service as a County Nurse Employee in Pennsylvania​PSRS 708
​Vital Papers and Other Important Information
​PSRS 1012
W-4P Federal Tax Withholding Certificate for Pension or Annuity Payments
​PSRS 996

Waiver of Pension Benefits
​PSRS 1286
 Contact PSERS to receive an Application for Disability Retirement.  To receive any other forms associated with a disability retirement or an Application for Refund, contact PSERS.