Member Forms

Active Member Forms

• Authorization for Release of Information - PSRS 1273 

• 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

• PSERS Verification of Deposit  - PSRS 1326

• Refund Application – Contact PSERS to acquire this form
  

• Retirement Application for a Disability Retirement – Requires counseling. Contact PSERS to acquire this form

Purchase of Service

• Purchase of Former Full-Time Uncredited Service  - PSRS 27

• Purchase of Non-Intervening Military Service  - PSRS 28

• Purchase of Former Part-Time Uncredited Service  - PSRS 100

• Application to Purchase Credit for an Approved Leave of Absence  - PSRS 112

• Purchase of Out-of-State Service  - PSRS 278

• Purchase of United States Government Service  - PSRS 600

• Application to Return Withdrawn Contributions  - PSRS 696

• Purchase of Pennsylvania County Nurse Service  - PSRS 708

• Rollover Certification Form  - PSRS 928

Retirement

• Application for Retirement  - PSRS 8

• Disability Retirement Explanation  - PSRS 123

• Request for Retirement Estimate  - PSRS 151

• Release for Medical Records  - PSRS 607

• Authorization for Direct Rollover (Retirement)  - PSRS 1264

• Retirement Packet  (99400)

Contact PSERS to receive an Application for Disability Retirement.  To receive any other forms associated with a disability retirement or an Application for Refund, contact PSERS .