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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
Guide to your PSERS-Issued Form 1099R ​PSRS 293 ​
​Agent's Acknowledgement  ​PSRS-248-1 ​√
​Authorization for Direct Rollover - Alternate Payee ​PSRS 1160 ​√
​​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
√​
​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
 ​PSRS 8 ​√
​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​Return Withdrawn Contributions ​PSRS 696 ​√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.  

 

 

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