Skip Ribbon Commands
Skip to main content
An Official Pennsylvania Government Website
Translate
Begin Main Content Area

​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
​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​Return Withdrawn Contributions​PSRS 696​√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.  

 

 

​