Forms
These forms are stored in PDF format. If you have the free Adobe Acrobat Reader software you can fill the forms out and print them, you cannot save them to another location. Please note that you must click the "clear" button in order to delete the information you entered into this form.
Click the Acrobat Reader icon to download this free program.
Please retain a copy of all completed forms for your records.
| General Forms | ||
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Address Change Form | |
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Name Change Form If your name has changed due to a marriage or a divorce, you may also need to fill out and submit a new Nomination of Beneficiary form. Click the link below to access that form. |
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Nomination of Beneficiary* Protecting Those You Care About Brochure |
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| *This Nomination of Beneficiary form should only be completed by an individual who is currently employed in a PSRS-covered district or by an individual who has an active membership with PSRS but is not currently working in a PSRS-covered district. If neither category applies, call our office at (800) 392-6848. | ||
| Purchasing Service Forms | ||
| If you are filling out a purchase application and plan to pay with money that is rolled over from a qualified account, please print and complete the Rollover/Transfer Certification form below. | ||
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Reinstatement Application | |
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PSRS Purchase of PEERS Credit | |
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Supplemental Credit Purchase Application | |
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Social Security Purchase Application | |
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A Detailed Earnings Statement from Social Security Administration is required. | |
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Public School Purchase Application | |
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Private School Purchase Application | |
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Maternity Leave Purchase Application | |
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Military Purchase Application | |
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Vo-Tech Purchase Application | |
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Not-for-Profit Purchase Application | |
| Rollover Form/Instruction Sheet | ||
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Rollover/Transfer Certification for Pre-Tax Funds (For the Purchase or Reinstatement of Service Credit) | |
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Rollover/Transfer for Pre-Tax Funds Instruction Sheet | |
| Getting Ready to Retire Forms | ||
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Tax Withholding Authorization | |
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Direct Deposit Authorization Form for Electronic Funds Transfer (EFT) | |
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Service Retirement Application Please print and complete the Tax Withholding Authorization (above), the Direct Deposit Authorization Form (above) and the $5000 Death Benefit Form with this application. If you plan to elect PLSO at retirement, you must file a PLSO Distribution Form with this application. |
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PLSO Distribution Form Complete this form only if you are filing for service retirement and selecting a PLSO plan. |
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Disability Retirement Application |
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| Survivor/Death Benefit Forms | ||
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Fall Semester Certification of School Official Form | |
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Spring Semester Certification of School Official Form | |
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Summer Certification of Parent/Guardian Form | |
Please call our office at (800) 392-6848 to request the following forms: |
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| Application for Withdrawal | ||
| Application to Purchase USERRA | ||
| Application to Purchase Reciprocity | ||
| Application to Purchase Part-Time Certificated Service | ||
| Application to Purchase Non-Federal Public Employment | ||
