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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.

Search Forms 

​Form NumberName​​Category
​PSRS 8Application for Retirement​Retirement
​PSRS 27 ​Application to Purchase Credit for Full-Time Service​Purchase of Service
​PSRS 28 ​Application for Credit for Military Service​​Purchase of Service
​PSRS 100Application to Purchase Credit for Part time Service​​Purchase of Service
​PSRS 112Application to Purchase Credit for an Approved Leave of Absence​​Purchase of Service
​PSRS 116 ​Authorization for Direct Deposit - Electronic Transfer of Monthly BenefitRetired Member
​PSRS 123 ​Disability Retirement Explanation​Retirement
​PSRS 151Request for Retirement Estimate​Retirement
PSRS 187​ Nomination of Beneficiaries Nomination of Beneficiary
​PSRS 248 ​Power of Attorney​Power of Attorney
​PSRS 248-1 Agent's Acknowledgement​​Power of Attorney
​PSRS 248-2 POA Florida Affidavit​​Power of Attorney
​PSRS 248-3 POA Non-Durable Affidavit​​Power of Attorney
​PSRS 248-4 POA Relationship Affidavit​​Power of Attorney
​PSRS 278Application for Credit for Out-of- State Service​Purchase of Service
​PSRS 293 Guide to your PSERS-Issued Form 1099R (SAMPLE)​
​Retired Member
​PSRS 349 ​Questionnaire to determine the applicant's eligibility for PSERS membershipActive Member  
​PSRS 600 ​Application for Credit for U.S. Government ServicePurchase of Service        
​PSRS 607Release for Medical Records​Retirement
​PSRS 631Option Designation Retired Member
​PSRS 696 ​Application to Return Withdrawn ContributionsPurchase of Service
​PSRS 708 ​Application for Service as a County Nurse Employee in Pennsylvania​Purchase of Service
​PSRS 928 Rollover Certification for Purchase of Creditable ServiceTaxes
​PSRS 996
W-4P Federal Tax Withholding Certificate for Pension or Annuity Payments
​PSRS 1012 ​Vital Papers and Other Important InformationActive Member
​PSRS 1127Purchase Maternity Leave of Absence (Commencing Prior to November 1, 1978)Purchase of Service
​PSRS 1128Application to Purchase Credit for Cadet Nurse Service​​Purchase of Service
​PSRS 1165 ​PSERS Health Options ProgramRetired Member
​PSRS 1245 Tax Information for Refunds​​Taxes
​PSRS 1253Nomination of Beneficiaries AddendumNomination of Beneficiary
​PSRS 1259Application for Multiple Service Membership​Active Member
​PSRS 1264 ​Authorization for Direct Rollover (Retirement)Retirement
​PSRS 1273 ​Authorization for Release of InformationActive Member
​PSRS 1286Waiver of Pension Benefits​Active Member
​PSRS 1301Change of Address for PSERS Retirees​Retired Member
​PSRS 1309 ​Request for Recalculation Estimate Due to Change in Marital Status or Death of Survivor Annuitant​Retired Member
​PSRS 1326PSERS Verification of Deposit
​Active Member
​PSRS 1332
Executor Request for PSERS Documents
​PSRS 99400 Retirement Packet​Retirement​

Major Medical Comprehensive Claim FormRetired Member

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.