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About Public Retirement

Forms Download

Instructions

Welcome to the ERSRI Forms Download page.

We recommend that you obtain all of your forms by downloading and printing them from this website. This ensures that you are using the most up-to-date version of the form that ERSRI has available. For your convenience, these forms have been categorized into Membership Forms, Retiree Forms and General Forms.You need to have the latest version of the Adobe® Acrobat® Reader® to download forms. You can download the latest version of Adobe® Acrobat® Reader® using the link below.

Once you have successfully installed the Adobe® Acrobat® Reader®, click on the links below to download the forms.

Membership Forms
General Membership Forms
	Beneficiary Nomination: Form that nominates a member's primary and contingent beneficiaries
	MERS Member Election: Optional form for Member election into ERSRI (only applicable for MERS plan)
	Post-Retirement Employment: Form to report post retirement employment to ERSRI

Optional Service Credit Forms
	Call Fire Fighter Credit Request: Form for purchasing call fire fighter credit
	Military Credit Request: Form for purchasing military credit
	Non-Participating Municipality Credit Request: Form for non-participating municipality credit
	Nurse Teaching Credit Request: Form for purchasing nurse teaching credit
	Official Layoff Verification: Form for purchasing official layoff
	Official Leave Verification: Form for purchasing official leave
	Out of State Teaching Credit Request: Form for purchasing out of state teaching credit
	Part-time Teacher Verification: Form for purchasing part-time teacher credit
	Payroll Deduction Authorization: Form for payroll deductions
	Peace Corps Credit Request: Form for purchasing peace corps credit
	Prior Time Verification: Form for purchasing prior time
	Private Teaching Credit Request: Form for purchasing private teaching credit
	Probationary Time Verification: Form for purchasing probationary time
	Refund Payback Request: Form for purchasing refund payback
	Substitute Teacher Verification: Form for purchasing substitute teacher credit
	Teacher Corps Credit Request: Form for purchasing teacher corps credit
	VISTA Credit Request: Form for purchasing VISTA credit
	Vocational Education Credit: Form for purchasing vocational education credit

Refund Forms
	Refunds Packet: Form to refund accumulated distributions to a member
	Agreement of Trustee/Custodian: Form that is an agreement between a member and financial institution. This form allows a member to rollover a refund into a qualified retirement account (i.e. IRA)

Retiree Forms
General Retirement Forms
	Tax Change: Form used to change the amount of tax withheld from a member's monthly paycheck
	Direct Deposit: Form that authorizes ERSRI to deposit your pension check directly into your bank account
	AETNA Designation of Beneficiary Form: Form that is used to nominate beneficiaries for AETNA Life Insurance Company

Health Forms
	COBRA: Form that gives the member the option to apply for COBRA benefits
	Health Care Cancellation Form: Form that gives the retirees the option to cancel health care benefits.

General Forms
Member/Retiree Forms
	Change of Information: Form that changes the name, address, and/or telephone number of a member
	Forgery Affidavit: Form completed by member when he/she thinks refund or benefit payment was forged
	Salary Verification for Purchases: Form for reporting salary for determining Service Credit
	Day Count Form for Teachers: Form for verification of contributing Service Credit