Forms

Account Login - Access your personal SERS account

Home

Forms

Retired 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	Disability Retirement Forms
Death Benefit Forms	Retirement Forms
	Other Forms

Beneficiary Form	PDF Fillable	PDF Non Fillable	HTML Instructions
Retired Member Beneficiary Nomination SERS-403	70 KB

Death Benefits Package - Forms and Information (also referred to as the "Act 500 Death Benefits Package")	PDF Fillable	PDF Non Fillable
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
Direct Deposit of Annuity Payments SERS-123	104 KB
Annual Earnings Statement for Disability Benefits SERS-220	101 KB
Withholding Certificate-Pension or Annuity Payments SERS-W-4P	121 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 Retiree Change Form PEBTF-10 This form is used to make changes to your REHP coverage such as adding or removing dependents. State Police Troopers use PEBTF-18	147 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
PEBTF State Police Retiree Change Form PEBTF-18 This form is used to make changes to your REHP coverage such as adding or removing dependents. For State Police Troopers Only	132 KB

Option Change Package - Forms and Information	PDF Fillable	PDF Non Fillable
Acknowledgement of Current Annuity Status SERS-300		30 KB
Disability Option Change Application SERS-303		63 KB
Disability Option Change Counseling Checklist SERS-303C		50 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 Retiree Change Form PEBTF-10 This form is used to make changes to your REHP coverage such as adding or removing dependents. State Police Troopers use PEBTF-18	147 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
PEBTF State Police Retiree Change Form PEBTF-18 This form is used to make changes to your REHP coverage such as adding or removing dependents. For State Police Troopers Only	132 KB
Regular Option Change Application SERS-329		34 KB
Regular Option Change Counseling Checklist SERS-329C		31 KB
Retired Member Beneficiary Nomination SERS-403	70 KB

Retirement Package - Forms and Information	PDF Fillable	PDF Non Fillable
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		236 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 Retiree Change Form PEBTF-10 This form is used to make changes to your REHP coverage such as adding or removing dependents. State Police Troopers use PEBTF-18	147 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
PEBTF State Police Retiree Change Form PEBTF-18 This form is used to make changes to your REHP coverage such as adding or removing dependents. For State Police Troopers Only	132 KB
Application for Annuity SERS-129		389 KB
Retired Member Beneficiary Nomination SERS-403	70 KB
Withholding Certificate-Pension or Annuity Payments IRS-W4P	72 KB

Other Forms and Information	PDF Fillable	PDF Non Fillable
Annuitant Change of Address SERS-128	39 KB
Authorization to Release Account Information SERS-405	44 KB
Authorization to Release Death Beneficiary Information SERS-405b	29 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 Retiree Change Form PEBTF-10 This form is used to make changes to your REHP coverage such as adding or removing dependents. State Police Troopers use PEBTF-18	147 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
PEBTF State Police Retiree Change Form PEBTF-18 This form is used to make changes to your REHP coverage such as adding or removing dependents. For State Police Troopers Only	132 KB
Installment Election Form APY42	45 KB
Next of Kin Affidavit SERS-167		28 KB
Power of Attorney SERS-296		63 KB
Sample Domestic Relations Order		103 KB

Last published: 05/15/2013 01:59 PM