MEMBER Forms

You can also view the forms in numeric order and/or alphabetical order.                

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

To avoid delays or errors, before you complete an application for retirement or disability retirement form, PSERS strongly suggests you attend one of our regular retirement counseling sessions in your area presented by a PSERS Regional Representative.                 

Membership Eligibility, Nomination of Beneficiary, and Other Active Member Forms

• Authorization for Release of Information (PDF) - PSRS 1273 

• Multiple Service Membership (PDF) - PSRS 1259

• Nomination of Beneficiaries  (PDF) - PSRS 187  

• Nomination of Beneficiaries Addendum (PDF) - PSRS 1253

• Vital Papers and Other Important Information (PDF) - PSRS 1012

• Waiver of Pension Benefits (PDF) - PSRS 1286

• PSERS Verification of Deposit (PDF) - PSRS 1326

• Purchase of Former Full-Time Uncredited Service (PDF) - PSRS 27

• Purchase of Non-Intervening Military Service (PDF) - PSRS 28

• Purchase of Former Part-Time Uncredited Service (PDF) - PSRS 100

• Application to Purchase Credit for an Approved Leave of Absence (PDF) - PSRS 112

• Purchase of Out-of-State Service (PDF) - PSRS 278

• Purchase of United States Government Service (PDF) - PSRS 600

• Application to Return Withdrawn Contributions (PDF) - PSRS 696

• Purchase of Pennsylvania County Nurse Service (PDF) - PSRS 708

• Rollover Certification Form (PDF) - PSRS 928

To avoid delays or errors - before you complete an application for retirement or disability retirement form, PSERS strongly suggests you attend one of our regular retirement counseling sessions in your area presented by a PSERS Regional Representative.

• Application for Retirement (PDF) - PSRS 8

• Disability Retirement Explanation (PDF) - PSRS 123

• Request for Retirement Estimate (PDF) - PSRS 151

• Release for Medical Records (PDF) - PSRS 607

• Authorization for Direct Rollover (Retirement) (PDF) - PSRS 1264

• Retirement Packet (PDF) (99400)

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 . 

Forms for Retirees, including Direct Deposit and information on the Health Options Program

• Authorization for Direct Deposit - Electronic Transfer of Monthly Benefit (PDF) - PSRS 116

• Power of Attorney (PDF) - PSRS 248

• Option Designation (For Retirees Whose Survivor Annuitant is Deceased) (PDF) - PSRS 631

• Major Medical Comprehensive Claim Form (PDF)

• PSERS Health Options Program (PDF) -  PSRS 1165    

• Change of Address for PSERS Retirees and Non-Active Members (PDF) - PSRS 1301

   

• Power of Attorney (PDF) - PSRS 248

• Agent's Acknowledgement  (PDF) - PSRS-248-1

• POA Relationship Affidavit (PDF) - PSRS-248-4

• POA Florida Affidavit  (PDF) - PSRS 248-2

• POA Non-Durable Affidavit (PDF) - PSRS 248-3

 

• Guide to your PSERS-Issued Form 1099R (PDF) - PSRS 293

• Rollover Certification for Purchase of Creditable Service (PDF) - PSRS 928

• Authorization for Direct Rollover - Alternate Payee  (PDF) - PSRS 1160

• Tax Information for Refunds (PDF) - PSRS 1245

• W-4P Federal Tax Withholding Certificate for Pension or Annuity Payments (PDF) - PSRS 996

• IRS Forms (Search for IRS forms using the IRS Search Forms feature on the left side of their site)