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Employer Forms

These forms may be viewed using the free Adobe Acrobat Reader.  

These forms are also available by contacting PSERS.
 

You may select a form from the following categories, 
or you may view and select a form from the entire forms list below.

 

Enrollment, Membership Eligibility,  Divorce, and Nomination of Beneficiary:  

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Purchase of Service: 

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Refunds:  

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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. 

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Forms for Retirees, including Direct Deposit and information on the Health Options Program: 

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Power of Attorney: 

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Taxes: 

 

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Form Number Form Name/Description
To avoid delays or errors, before you complete an "Application for Retirement" form, PSERS strongly suggests you attend one of our regular retirement counseling sessions in your area presented by a PSERS Regional Representative.
99400 (02/2010)
Exit Retirement Package 		Exit Retirement Package Includes:
Exit Letter
Submitting an Application
PSRS-1264 Authorization for Direct Rollover (Retirement)
PSRS-8 Application For Retirement
PSRS 27 (06/2005) Application to Purchase Credit for Full-Time Service
PSRS 28 (06/2005) Application for Credit for Military Service
99600 (02/2010)

Application for Refund
Package includes:

PSRS-59 - Guidelines for completing your application for retirement.
PSRS-59 - Application for Refund
PSRS-1243 - Authorization for Direct Rollover (Refund)

Submitting an Application for Retirement
Let's Talk About Leaving Employment and Your PSERS 
PSRS 100 (07/2005) Application to Purchase Credit for Part time Service
PSRS 112 (06/2005) Application to Purchase Credit for an Approved Leave of Absence
PSRS 116 (05/2007) Authorization for Direct Deposit - Electronic Transfer of Monthly Benefit
PSRS 123 (04/2009) Disability Retirement Explanation
PSRS 151 (04/2009) Request for Retirement Estimate
PSRS 187 (05/2005) Nomination of Beneficiaries
PSRS 1253 (02/2001) Nomination of Beneficiaries Addendum
PSRS 248 (09/2008) Power of Attorney
PSRS 278 (06/2005) Application for Credit for Out-of- State Service
PSRS 349 (12/2005) Questionnaire to determine the applicant's eligibility for PSERS membership
PSRS 600 (06/2005) Application for Credit for U.S. Government Service
PSRS 607 (01/2000) Release for Medical Records
PSRS 631 (09/2002) Option Designation
PSRS 696 (06/2005) Application to Return Withdrawn Contributions
PSRS 708 (01/2000) Application for Service as a County Nurse Employee in Pennsylvania
PSRS 928 (06/2005) Rollover Certification for Purchase of Creditable Service
PSRS 996 (12/2009) W-4P Federal Tax Withholding Certificate for Pension or Annuity Payments
PSRS 1012 (06/2002) Vital Papers and Other Important Information
PSRS 1127 (06/2005) Application to Purchase Maternity Leave of Absence (Commencing Prior to November 1, 1978)
PSRS 1128 (01/2000) Application to Purchase Credit for Cadet Nurse Service
PSRS 1160 (02/2007) Authorization for Direct Rollover - Alternate Payee
PSRS 1165 (10/2006) PSERS Health Insurance Program
PSRS 1236 (03/2000) Physician's Medical Report
PSRS 1237 (01/2007) Job Description
PSRS 1238 (02/2000) Application to Re Apply for Renewal of Disability Retirement
PSRS 1243 (02/2007) Authorization for Direct Rollover - Refund
99700 (5/2007) (previously PSRS 1244 )

Application for Refund - Multiple Installments
Package includes:

PSRS 1244 - Guidelines for Completing Your Application For Refund - Installments
PSRS 1244 - Application for Refund - Installments
PSRS 1278 - Authorization for Direct Rollover (Installment)

Submitting an Application For Retirement
Let's Talk About Leaving Employment 

PSRS 1246 (04/2007) Application for Partial Refund (Non-qualifying Service)
PSRS 1248 (06/2003) Notice of Election to Accept or Waive a Retirement Benefit
PSRS 1259 (06/2005) Application for Multiple Service Membership
PSRS 1264 (02/2007) Authorization for Direct Rollover (Retirement)
PSRS 1273 (05/2001) Authorization for Release of Information
PSRS 1278 (02/2007) Authorization for Direct Rollover (Installment)
PSRS 1286 (03/2009) Waiver of Pension Benefits
PSRS 1301 (2/2009) Change of Address for PSERS Retirees
PSRS 1305 (6/2005) Intervening or Activated Military Service
Important Information for New Employees Important Information for New Employees
Internal Revenue Service Forms Internal Revenue Service Forms

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Public School Employees' Retirement System. All rights reserved.

This page was last updated 01/19/10