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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
Retired Member Beneficiary Nomination, Fillable PDF
 
Retired Member Beneficiary Nomination, 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
Direct Deposit of Annuity Payments
SERS-123
104 KB
Direct Deposit of Annuity Payments, Fillable PDF
 
Direct Deposit of Annuity Payments, HTML
Annual Earnings Statement for Disability Benefits
SERS-220
101 KB
Direct Deposit of Annuity Payments, Fillable PDF
   
Withholding Certificate-Pension or Annuity Payments
SERS-W-4P
121 KB
Withholding Certificate-Pension or Annuity Payments, 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.
 

350 KB
PEBTF Retiree Enrollment Form, NonFillable PDF

 

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

 

334 KB
PEBTF Retiree Change Form, 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
 
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
PEBTF State Police Retiree Change Form, Fillable PDF
   
 
Option Change Package - Forms and Information
PDF Fillable
PDF Non Fillable
HTML
Instructions
Acknowledgement of Current Annuity Status
SERS-300
 
30 KB
Acknowledgement of Current Annuity Status, Non-fillable PDF
 
Disability Option Change Application
SERS-303
 
63 KB
Disability Option Change Application, Non-fillable PDF
Disability Option Change Application, HTML
Disability Option Change Counseling Checklist
SERS-303C
 
50 KB
Disability Option Change Counseling Checklist, 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.
 

350 KB
PEBTF Retiree Enrollment Form, NonFillable PDF

 

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

  334 KB
PEBTF Retiree Change Form, 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, NonFillable PDF
 
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
PEBTF State Police Retiree Change Form, Fillable PDF
   
Regular Option Change Application
SERS-329
 
34 KB
Regular Option Change Application, Non-fillable PDF
Regular Option Change Application, HTML
Regular Option Change Counseling Checklist
SERS-329C
 
31 KB
Regular Option Change Counseling Checklist, Non-fillable PDF
 
Retired Member Beneficiary Nomination
SERS-403
70 KB
Retired Member Beneficiary Nomination, Fillable PDF
 
Retired Member Beneficiary Nomination, HTML
 
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
 
236 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.
 
350 KB
PEBTF Retiree Enrollment Form, Non-fillable PDF
 

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

  334 KB
PEBTF Retiree Change Form, 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, NonFillable PDF
 

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
PEBTF State Police Retiree Change Form, Fillable PDF
   
Application for Annuity
SERS-129
 
389 KB
Application for Annuity, Non-fillable PDF
 
Retired Member Beneficiary Nomination
SERS-403
70 KB
Retired Member Beneficiary Nomination, Fillable PDF
 
Retired Member Beneficiary Nomination, HTML
Withholding Certificate-Pension or Annuity Payments
IRS-W4P
72 KB
Withholding Certificate-Pension or Annuity Payments, 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
 
Annuitant Change of Address
SERS-128
119 KB
Annuitant Change of Address, 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
   

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.

  350 KB
PEBTF Retiree Enrollment Form, NonFillable PDF
 

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

  334 KB
PEBTF Retiree Change Form, 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, NonFillable PDF
 
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
PEBTF State Police Retiree Change Form, Fillable PDF
   
Installment Election Form
APY42
45 KB
APY42_Installment_Election_Form.pdf, 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
Sample Domestic Relations Order
 
 
103 KB
Sample Domestic Relations Order, Fillable PDF
Sample Domestic Relations Order, HTML

    



Last published: 07/23/2014 11:33 AM