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.

• Membership Eligibility, Divorce, and Nomination of Beneficiary
• Purchase of Service
• Retirement
• Forms for Retirees, including Direct Deposit and information on the Health Options Program
• Power of Attorney
• Taxes

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, Divorce, and Nomination of Beneficiary

• Authorization for Release of Information - PSRS 1273
• Authorization to Release Fax Information - PSRS 1316 NEW
• Multiple Service Membership - PSRS 1259
• Nomination of Beneficiaries - PSRS 187  
• Nomination of Beneficiaries Addendum - PSRS 1253
• Vital Papers and Other Important Information - PSRS 1012
• Waiver of Pension Benefits - PSRS 1286

Purchase of Service

• Purchase Credit for Full-Time Service - PSRS 27
• Credit for Military Service - PSRS 28
• Purchase Credit for Part Time Service - PSRS 100
• Purchase Credit for an Approved Leave of Absence - PSRS 112
• Credit for Out-of-State Service - PSRS 278
• Credit for US Government Service - PSRS 600
• Return Withdrawn Contributions - PSRS 696
• Service as a County Nurse Employee in Pennsylvania - PSRS 708
• Rollover Certification for Purchase of Creditable Service - PSRS 928
• Purchase Maternity Leave of Absence - PSRS 1127
• Purchase Credit for Cadet Nurse Service - PSRS 1128
• Intervening or Activated Military Service - PSRS 1305

Retirement
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 - PSRS 8
• Disability Retirement Explanation - PSRS 123
• Request for Retirement Estimate - PSRS 151
• Release for Medical Records - PSRS 607
• Physician's Medical Report - PSRS 1236
• Job Description - PSRS 1237
• Application to Re Apply for Renewal of Disability Benefit - PSRS 1238
• Notice of Election to Accept or Waive a Retirement Benefit - PSRS 1248
• Authorization for Direct Rollover (Retirement) - PSRS 1264
• Retirement Packet (99400)

Contact your PSERS regional office to receive an Application for Disability Retirement.  To receive 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 - PSRS 116
• Power of Attorney - PSRS 248
• Option Designation (For Retirees Whose Survivor Annuitant is Deceased) - PSRS 631
• Major Medical Comprehensive Claim Form
• Change of Address for PSERS Retirees - PSRS 1301