All forms on this website are available in PDF format only, best viewed with Adobe Acrobat Reader version 7. If you would like to view and print (where applicable) these forms and you do not have a copy of Acrobat Reader you can get the latest version at no cost from Adobe's website.

Forms provided in "PDF Fillable" format may be filled in online, printed, signed and returned to SERS.

Forms provided in "PDF Non Fillable" format are provided here as a sample only, so that you know what information you will need to complete the form when you meet with your Retirement Counselor. 

Beneficiary Form	PDF Fillable	PDF Non Fillable	HTML Instructions
Active/Vested Beneficiary Nomination For Active/Inactive Members SERS-402	112 KB

Death Benefits Package - Forms and Information (also referred to as the "Act 500 Death Benefits Package")	PDF Fillable	PDF Non Fillable	HTML Instructions
Authorization for Direct Rollover SERS-255	135 KB
Death Benefit Payment Option Selection Form BEN66		55 KB
Release and Indemnification Affidavit to Obtain Retirement Benefits Due Beneficiaries of Deceased Members BEN67		34 KB
Important Information--For Benefits Payable in Amounts Over $10,000		22 KB
Important Information--For Benefits Payable in Amounts Under $10,000		20 KB
Important Information--For Guaranteed Present Value		17 KB

Disability Retirement Package  Forms and Information	PDF Fillable	PDF Non Fillable	HTML Instructions
Annual Earnings Statement for Disability Benefits SERS-220	101 KB
Agency Notification Letter SERS-292		328 KB
Direct Deposit of Annuity Payments SERS-123	104 KB
Disability Medical Report SERS-144	77 KB
Disability Retirement Application - Non-Vested SERS-103N		378 KB
Disability Retirement Application - Vested SERS-103		386 KB
Medicare Eligibility and REHP Coverage Acknowledgement OA-286 This form is provided on this site as a sample only, an actual form will be provided to you by your Retirement Counselor.  Every member enrolling in REHP must complete this form acknowledging that you understand that if you or your REHP-eligible dependent become eligible for Medicare, REHP will NOT cover any Medicare-covered costs. State Police Troopers use OA-287		237 KB
Medicare Eligibility and RPSPP Coverage Acknowledgement OA-287 This form is provided on this site as a sample only, an actual form will be provided to you by your Retirement Counselor.  Every member enrolling in RPSPP must complete this form acknowledging that you understand that if you or your RPSPP-eligible dependent become eligible for Medicare, RPSPP will NOT cover any Medicare-covered costs. For State Police Troopers Only		26 KB
PEBTF Retiree Enrollment Form PEBTF-9 This form is used to enroll in REHP group coverage at the time of retirement or to cancel coverage. State Police Troopers use PEBTF-17 Note: The PEBTF requires a PEBTF Dependent Attestation Form (PEBTF-16) for each dependent who is new to a PEBTF plan and between the ages of 19 and 26 who are added to coverage.		277 KB
PEBTF Dependent Attestation Form PEBTF-16 This form is to be used to add a dependant who is new to a PEBTF plan and between the ages of 19 and 26.	31 KB
PEBTF State Police Retiree Enrollment Form PEBTF-17 This form is used to enroll in REHP group coverage at the time of retirement or to cancel coverage. For State Police Troopers Only		82 KB
Withholding Certificate-Pension or Annuity Payments SERS-W-4P	121 KB

New Member Package - Forms and Information	PDF Fillable	PDF Non Fillable	HTML Instructions
This is a sample of the New Member Package for employees who enter SERS membership on or after January 1, 2011 (for legislators, Dec. 1, 2010; for Capitol Police Officers and Park Rangers, July 1, 2011; for State Police Officers, July 1, 2012) as a member of the A-3 Class of Service (including those who subsequently elect membership in the A-4 Class).  The forms in this PDF file are for informational purposes only, not for completion.  If you do not receive your New Member Package by mail, or you lose a form, please contact a SERS Retirement Counselor for a replacement.		1.8 MB
This is a sample of the New Member Package for employees who have prior SERS service in any of the Pre-Act 120 Classes of Service and are returning to active service or employment with a SERS employer.  The forms in this PDF file are for informational purposes only, not for completion.  If you do not receive your New Member Package by mail, or you lose a form, please contact a SERS Retirement Counselor for a replacement.		1.4 MB

Purchase of Service Forms	PDF Fillable	PDF Non Fillable	HTML Instructions
Request for Purchase of Service SERS-131	64 KB
Request for Multiple Service SERS-400	72 KB
Request for Out-of-State Service Credit SERS-104	161 KB

Refund Package - Forms and Information	PDF Fillable	PDF Non Fillable	HTML Instructions
Application for Refund of Member Contributions and Interest SERS-251		68 KB
Authorization for Direct Rollover SERS-254	147 KB
Refund Affidavit of Membership SERS-291	45 KB
Refund Counseling Checklist SERS-351		41 KB
Sample Refund Letter DST05		58 KB

Retirement Package - Forms and Information	PDF Fillable	PDF Non Fillable	HTML Instructions
Authorization for Direct Rollover SERS-254	147 KB
Agency Notification Letter SERS-292		328 KB
Direct Deposit of Annuity Payments SERS-123	104 KB
Medicare Eligibility and REHP Coverage Acknowledgement OA-286 This form is provided on this site as a sample only, an actual form will be provided to you by your Retirement Counselor.  Every member enrolling in REHP must complete this form acknowledging that you understand that if you or your REHP-eligible dependent become eligible for Medicare, REHP will NOT cover any Medicare-covered costs. State Police Troopers use OA-287		237 KB
Medicare Eligibility and RPSPP Coverage Acknowledgement OA-287 This form is provided on this site as a sample only, an actual form will be provided to you by your Retirement Counselor.  Every member enrolling in RPSPP must complete this form acknowledging that you understand that if you or your RPSPP-eligible dependent become eligible for Medicare, RPSPP will NOT cover any Medicare-covered costs. For State Police Troopers Only		26 KB
PEBTF Retiree Enrollment Form PEBTF-9 This form is used to enroll in REHP group coverage at the time of retirement or to cancel coverage. State Police Troopers use PEBTF-17 Note: The PEBTF requires a PEBTF Dependent Attestation Form (PEBTF-16) for each dependent who is new to a PEBTF plan and between the ages of 19 and 26 who are added to coverage.		277 KB
PEBTF Dependent Attestation Form PEBTF-16 This form is to be used to add a dependant who is new to a PEBTF plan and between the ages of 19 and 26.	31 KB
PEBTF State Police Retiree Enrollment Form PEBTF-17 This form is used to enroll in REHP group coverage at the time of retirement or to cancel coverage. For State Police Troopers Only		82 KB
Application for Annuity SERS-129		389 KB
Withholding Certificate-Pension or Annuity Payments SERS-W-4P	121 KB

Vesting Package - Forms and Information	PDF Fillable	PDF Non Fillable	HTML Instructions
Active/Vested Beneficiary Nomination SERS-402	112 KB
Agency Notification Letter SERS-292		328 KB
Vesting Application SERS-140		314 KB
Sample Vesting Notice		87 KB

Other Forms and Information	PDF Fillable	PDF Non Fillable	HTML Instructions
Authorization to Release Account Information SERS-405	44 KB
Authorization to Release Death Beneficiary Information SERS-405b	29 KB
Next of Kin Affidavit SERS-167		28 KB
Power of Attorney SERS-296		63 KB
Retirement Estimate Request SERS-124	156 KB
Sample Domestic Relations Order		103 KB