Forms

Defined Benefit Plan Forms

Within days of your enrollment in SERS, we send a packet of information to your home. Please read it carefully and double check the information we provide to ensure that it is accurate. You'll notice that some decisions you need to make are time-sensitive, so please promptly complete and return forms in the self-addressed envelope provided. If you need additional copies of the forms, you can download them here.

Your retirement benefit is an important and, often, substantial part of your compensation package. Some decisions you make are permanent; other decisions may be carried out after your death.

It is crucial that you take great care in managing your retirement benefit. Do not complete a form that you do not understand. If you have any questions, please call 1.800.633.5461 and a SERS professional will assist you. When you do complete a form, please ensure that it is 100% complete, accurate, and accompanied by appropriate supporting documentation, if necessary.

Some forms, such as applications for annuities, must be completed with the assistance of a SERS retirement counselor. Other forms, such as domestic relations orders or powers of attorney, require a third-party to complete, such as a court or a notary. Many members have told us that it is extremely helpful to see these types of forms and to be able to gather required information prior to being asked to complete them. Thus, this page provides sample copies of many forms for your information.

Most Common Forms

Defined Benefit Pension Beneficiary Nomination Form
Class A-4 Election
Direct Deposit of Pension Payments
Annuitant - Change of Address
Multiple Service Election
Retirement Estimate Request
Service Purchase Request
Power of Attorney (sample)
Authorization to Release Account Information
Right-to-Know Law Disclosure of Home Address Exception Documentation
Domestic Relations Order (sample)

Leave State Employment without Retiring (Refund)

Authorization for Direct Rollover

Disability Retirement

Disability Medical Report
Direct Deposit of Pension Payments
Tax Withholding Certificate - Pension or Annuity Payments

Retirement

Direct Deposit of Pension Payments
Tax Withholding Certificate - Pension or Annuity Payments
Authorization for Direct Rollover

Death Benefits

Authorization to Release Death Beneficiary Information
Release & Indemnification Affidavit to Obtain Retirement Benefits Due Beneficiaries of Deceased Members 
Authorization for Direct Rollover 


You can return completed forms to:

Pennsylvania State Employees' Retirement System
30 North 3rd Street, Suite 150
Harrisburg, PA 17101

or

Fax: 717.237.0346