Forms

Overview Michael Fara

Forms

Michael Fara

Some forms require Adobe Acrobat Reader. If you don’t have the most recent version, please download Adobe Acrobat Reader (free). 

Submit These Forms Online! 

Log in to Account to submit:

  • Address and Name Change (Retired and Deferred Members Only)
  • Federal and State Withholding
  • Purchase / Redeposit Request
  • Retirement Estimate Request
Download Michael Fara

80% Authorization Form

Michael Fara
Download Michael Fara

Active and Deferred Data Correction Form

Michael Fara
Download Michael Fara

Active or Deferred Member Beneficiary Designation Form

Michael Fara

To designate or re-designate your beneficiary, return this completed form to ACERA.

Download Michael Fara

Address and Name Change Form for Retired Members, Payees, and Deferred Members

Michael Fara
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Affidavit of Dependent Eligibility

Michael Fara
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Affidavit of Domestic Partnership

Michael Fara
Download Frank Vickers

Agreement and Order for Division of Retirement Benefits – Separate Records

Frank Vickers
Download Frank Vickers

Agreement and Order for Division of Retirement Benefits – Shared Records

Frank Vickers
Download Lee Lewis

Application For Disability Retirement (Sample Only)

Lee Lewis
Download Michael Fara

Application for Service Retirement

Michael Fara

When you are within 60 days of your chosen retirement date, you may complete and submit an ACERA retirement application. On your retirement application you will write your chosen retirement date as well as choose a beneficiary or beneficiaries for continuance death benefits. You can even submit an application the day before you retire.

Download Michael Fara

Aquilino Tier I Restoration Application

Michael Fara
Download admin

Authorization for Release of Information and Documents

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Download Frank Vickers

Community Property Estimate Request Form

Frank Vickers
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Confidentiality Policy

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Declaration of Qualification for Registration as Domestic Partners

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Download Michael Fara

Dental Plan Enrollment Form

Michael Fara

Use this form to enroll in an ACERA dental plan.

Download Michael Fara

Direct Deposit Form

Michael Fara
Download Lee Lewis

HIPAA Authorization Form

Lee Lewis
Download Lee Lewis

HIPAA Cancellation Form

Lee Lewis
Download admin

IRS Form W-9

admin
Download Michael Fara

Medical Enrollment Form

Michael Fara

Use this form to enroll in all ACERA medical plans except for individual plans through Via Benefits and individual Kaiser Permanente plans outside of California.

Download bramirez@acera.org

Medicare Part B Reimbursement Plan (MBRP) Application Form

bramirez@acera.org
Download Lee Lewis

New Member Enrollment Questionnaire

Lee Lewis
Download Lee Lewis

Non-Member Application for Retirement Allowance

Lee Lewis
Download Michael Fara

Non-Member Beneficiary Form

Michael Fara
Download admin

Notice of Claim

admin
Download Lee Lewis

Other Public Service Verification Form

Lee Lewis
Download Frank Vickers

Power of Attorney

Frank Vickers
Download Michael Fara

Purchase Request Form

Michael Fara

Use this form for ask ACERA to calculate the cost of purchasing eligible time as service credit. Learn more about service credit on our service credit page.

Post Michael Fara

Reimbursement Forms for Via Benefits Plans
(Formerly OneExchange)

Michael Fara

Prior to submitting reimbursements, read Making Your Via Benefits Medicare Reimbursements Easier for how to set up recurring reimbursements and other helpful information.

Then visit https://my.viabenefits.com/acera to file reimbursement claims for healthcare expenses in Via Benefits healthcare plans.

Download Michael Fara

Report a Death Form

Michael Fara

Click here to report a death.

Download admin

Request for Joinder Packet

admin
Download Michael Fara

Retired Member Beneficiary Designation Form

Michael Fara
Download Lee Lewis

Retirement Estimate Request Form

Lee Lewis
Download Michael Fara

SSA-44 Form (Medicare Income-Related Monthly Adjustment Form)

Michael Fara
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Survivor Continuance Recipient’s Designation of Beneficiaries Form

admin
Download Michael Fara

Tax Withholding Designation Form (IRS Federal Form W-4P)

Michael Fara

Use the IRS Tax Withholding Estimator to calculate your withholding. It works really well.

Note: ACERA does not allow you to withhold a flat amount with no allowances. This means you MUST enter a number in the Allowances box (box 2).

Download Michael Fara

Tax Withholding Designation Form (State of California / Withholding Certificate for Pension or Annuity Payments)

Michael Fara
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Termination Election of Membership Request Form

Michael Fara
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Termination of Domestic Partnership

Michael Fara
Download admin

Verification of Enrollment Status

admin
Post Michael Fara

Via Benefits Reimbursement Forms
(Formerly OneExchange)

Michael Fara

Prior to submitting reimbursements, read Making Your Via Benefits Medicare Reimbursements Easier for how to set up recurring reimbursements and other helpful information.

Then visit https://my.viabenefits.com/acera to file reimbursement claims for healthcare expenses in Via Benefits healthcare plans.

Download Michael Fara

Vision Plan Enrollment Form

Michael Fara

Use this form to enroll in an ACERA vision plan.

Download Lee Lewis

VSP Reimbursement Form

Lee Lewis

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