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​Forms:  Numeric Order

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

​Form Number Name​ ​Fillable
​PSRS 8 Application for Retirement
​PSRS 27 ​Application to Purchase Credit for Full-Time Service
​PSRS 28 ​Application for Credit for Military Service
​PSRS 100 Application to Purchase Credit for Part time Service
​PSRS 112 Application to Purchase Credit for an Approved Leave of Absence
​PSRS 116 ​Authorization for Direct Deposit - Electronic Transfer of Monthly Benefit
​PSRS 123 ​Disability Retirement Explanation
​PSRS 151 Request for Retirement Estimate
PSRS 187​

Nomination of Beneficiaries

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​PSRS 248 ​Power of Attorney
​PSRS 278 Application for Credit for Out-of- State Service
​PSRS 293 Guide to your PSERS-Issued Form 1099R
​PSRS 349 ​Questionnaire to determine the applicant's eligibility for PSERS membership
​PSRS 600 ​Application for Credit for U.S. Government Service
​PSRS 607 Release for Medical Records
​PSRS 631 Option Designation
​PSRS 696 ​Application to Return Withdrawn Contributions
​PSRS 708 ​Application for Service as a County Nurse Employee in Pennsylvania
​PSRS 928 Rollover Certification for Purchase of Creditable Service
​PSRS 996 W-4P Federal Tax Withholding Certificate for Pension or Annuity Payments
​PSRS 1012 ​Vital Papers and Other Important Information
​PSRS 1127 Purchase Maternity Leave of Absence (Commencing Prior to November 1, 1978)
​PSRS 1128 Application to Purchase Credit for Cadet Nurse Service
​PSRS 1160 Authorization for Direct Rollover - Alternate Payee
​PSRS 1165 ​PSERS Health Options Program
​PSRS 1253 Nomination of Beneficiaries Addendum
​PSRS 1259 Application for Multiple Service Membership
​PSRS 1264 ​Authorization for Direct Rollover (Retirement)
​PSRS 1273 ​Authorization for Release of Information
​PSRS 1286 Waiver of Pension Benefits
​PSRS 1301 Change of Address for PSERS Retirees
​PSRS 1309 ​Request for Recalculation Estimate Due to Change in Marital Status or Death of Survivor Annuitant
​PSRS 1326 PSERS Verification of Deposit

Contact your PSERS regional office to receive an Application for Disability Retirement.  To receive any other forms associated with a disability retirement or an Application for Refund, contact PSERS.