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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 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Return Withdrawn Contributions ​PSRS 696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.