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Active Member Forms

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
Active/Vested Beneficiary Nomination For Active/Inactive Members, Fillable PDF
 
Active/Vested Beneficiary Nomination For Active/Inactive Members, HTML
 
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
Authorization for Direct Rollover, Fillable PDF
   
Death Benefit Payment Option Selection Form
BEN66
 
55 KB
Death Benefit Payment Option Selection Form, Non-fillable PDF
 
Release and Indemnification Affidavit to Obtain Retirement Benefits Due Beneficiaries of Deceased Members
BEN67
  
34 KB
Release and Indemnification Affidavit to Obtain Retirement Benefits Due Beneficiaries of Deceased Members, Non-fillable PDF
 
Important Information--For Benefits Payable in Amounts Over $10,000  
22 KB
Important Information--For Benefits Payable in Amounts Over $10,000, Non-fillable PDF

Important Information--For Benefits Payable in Amounts Over $10,000, HTML

Important Information--For Benefits Payable in Amounts Under $10,000  
20 KB
Important Information--For Benefits Payable in Amounts Under $10,000, Non-fillable PDF
Important Information--For Benefits Payable in Amounts Under $10,000, HTML
Important Information--For Guaranteed Present Value  
17 KB
Important Information--For Guaranteed Present Value, Non-fillable PDF
 
 
Disability Retirement Package 
Forms and Information
PDF
Fillable
PDF
Non
Fillable
HTML
Instructions
Annual Earnings Statement for Disability Benefits
SERS-220
101 KB
Annual Earnings Statement for Disability Benefits, Fillable PDF
   
Agency Notification Letter
SERS-292
 
328 KB
Agency Notification Letter, Non-fillable PDF
 
Direct Deposit of Annuity Payments
SERS-123
104 KB
Direct Deposit of Annuity Payments, Fillable PDF
 
Direct Deposit of Annuity Payments, HTML
Disability Medical Report
SERS-144
306 KB
Disability Medical Report, Fillable PDF
   
Disability Retirement Application - Non-Vested
SERS-103N
 
378 KB
Disability Retirement Application - Non-Vested, Non-fillable PDF
Disability Retirement Application - Non-Vested, HTML
Disability Retirement Application - Vested
SERS-103
 
386 KB
Disability Retirement Application - Vested, Non-fillable PDF
 
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 & REHP Coverage Acknowledgement, Non-Fillable PDF
 
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
Medicare Eligibility and RPSPP Coverage Acknowledgement, Non-Fillable PDF
 
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 Retiree Enrollment Form, Non-Fillable PDF
 
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
PEBTF State Police Retiree Enrollment Form, Non-Fillable PDF
 
Withholding Certificate-Pension or Annuity Payments
SERS-W-4P
121 KB
Withholding Certificate-Pension or Annuity Payments, fillable PDF
   
 
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
SERS New Member Package Class A-3, Non-fillable PDF
 
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
SERS New Member Package Pre Act 120 Form, Non-fillable PDF
 
 
Purchase of Service Forms
PDF
Fillable
PDF
Non
Fillable
HTML
Instructions
Request for Purchase of Service
SERS-131
64 KB
Request for Purchase of Service, fillable PDF
 
Request for Purchase of Service, HTML
Request for Multiple Service
SERS-400
72 KB
Request for Multiple Service, Fillable PDF
 
Request for Multiple Service, HTML
Request for Out-of-State Service Credit
SERS-104
161 KB
Request for Out-of-State Service Credit, Fillable PDF
 
Request for Out-of-State Service Credit, HTML
 
Refund Package - Forms and Information
PDF
Fillable
PDF
Non
Fillable
HTML
Instructions
Application for Refund of Member Contributions and Interest
SERS-251
 
68 KB
Application for Refund of Member Contributions and Interest, Non-fillable PDF
 
Authorization for Direct Rollover
SERS-254
147 KB
Authorization for Direct Rollover, Fillable PDF
   
Refund Affidavit of Membership
SERS-291
45 KB
Refund Affidavit of Membership, Fillable PDF
   
Refund Counseling Checklist
SERS-351
 
41 KB
Refund Counseling Checklist, Non-fillable PDF
 
Sample Refund Letter
DST05
 
58 KB
Sample Refund Letter, Non-fillable PDF
 
 
Retirement Package - Forms and Information
PDF
Fillable
PDF
Non
Fillable
HTML
Instructions
Authorization for Direct Rollover
SERS-254
147 KB
Authorization for Direct Rollover, Fillable PDF
   
Agency Notification Letter
SERS-292
 
328 KB
Agency Notification Letter, Non-fillable PDF
 
Direct Deposit of Annuity Payments
SERS-123
104 KB
Direct Deposit of Annuity Payments, Fillable PDF
 
Direct Deposit of Annuity Payments, HTML
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 & REHP Coverage Acknowledgement, Non-Fillable PDF
 
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
Medicare Eligibility and RPSPP Coverage Acknowledgement, Non-Fillable PDF
 
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 Retiree Enrollment Form, Non-fillable PDF
 
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
PEBTF State Police Retiree Enrollment Form, Non-fillable PDF
 
Application for Annuity
SERS-129
 
389 KB
Application for Annuity, Non-fillable PDF
 
Withholding Certificate-Pension or Annuity Payments
SERS-W-4P
121 KB
Withholding Certificate-Pension or Annuity Payments, Fillable PDF
   
 
Vesting Package - Forms and Information
PDF
Fillable
PDF
Non
Fillable
HTML
Instructions
Active/Vested Beneficiary Nomination
SERS-402
112 KB
Active/Vested Beneficiary Nomination, Fillable PDF
 
Active/Vested Beneficiary Nomination, HTML
Agency Notification Letter
SERS-292
 
328 KB
Agency Notification Letter, Non-fillable PDF
 
Vesting Application
SERS-140
 
314 KB
Vesting Application, Non-fillable PDF
 
Sample Vesting Notice
 
87 KB
Sample Vesting Notice, Non-fillable PDF
 
 
Other Forms and Information
PDF
Fillable
PDF
Non
Fillable
HTML
Instructions
Right-to-Know Law Disclosure of Home Address Exception Documentation   233 KB
Right-to-Know Law Disclosure of Home Address Exception Documentation, Non-Fillable PDF
 
Authorization to Release Account Information
SERS-405
44 KB
Authorization to Release Account Information, Fillable PDF
   
Authorization to Release Death Beneficiary Information
SERS-405b
29 KB
Authorization to Release Death Beneficiary Information, Fillable PDF
   
Next of Kin Affidavit
SERS-167
 
28 KB
Next of Kin Affidavit, Non-fillable PDF
 
Power of Attorney
SERS-296
 
63 KB
Power of Attorney, Non-fillable PDF
Power of Attorney, HTML
Retirement Estimate Request
SERS-124
156 KB
Retirement Estimate Request, Fillable PDF
   
Sample Domestic Relations Order
 
103 KB
Sample Domestic Relations Order, Non-fillable PDF
Sample Domestic Relations Order, HTML


Last published: 04/15/2014 09:34 AM