Forms

Overview

Submit These Web Forms In Your Account

  • Address and Name Change (Retired and Deferred Members Only)
  • Purchase / Redeposit Request
  • Retirement Estimate Request

Log Into Your Account

DocuSign and PDF Forms

Avoid paper, ink, scanning, and hassle with DocuSign E-Forms.

PDF forms require Adobe Acrobat Reader (free). 

Form DocuSign E-Form PDF
ACRE Enrollment Form   PDF
Active or Deferred Member Beneficiary Designation Form   PDF
Address and Name Change Form (Retirees, Payees, and Deferred Members)   PDF
Affidavit of Dependent Eligibility DocuSign PDF
Affidavit of Domestic Partnership   PDF
Agreement and Order for Division of Retirement Benefits – Separate Records   PDF
Agreement and Order for Division of Retirement Benefits – Shared Records   PDF
Application For Disability Retirement (Sample Only)   PDF
Application for Service Retirement DocuSign  
Aquilino Tier 1 Restoration Application   PDF
Authorization for Release of Information and Documents   PDF
Community Property Estimate Request Form   PDF
Confidentiality Policy   PDF
Continuance Beneficiary Addendum DocuSign  
Declaration of Qualification for Registration as Domestic Partners   PDF
Dental Plan Enrollment Form DocuSign PDF
Direct Deposit Form   PDF
HIPAA Authorization Form   PDF
HIPAA Cancellation Form   PDF
IRS Form W-9   PDF
Kaiser Permanente Senior Advantage (KPSA) Enrollment Form DocuSign PDF
Lump-Sum Death Benefit Beneficiary Addendum DocuSign  
Medical Plan Enrollment Form DocuSign PDF
Medicare Part B Reimbursement Plan (MBRP) Application Form DocuSign PDF
Member Enrollment Questionnaire   PDF
Non-Member Application for Retirement Allowance   PDF
Non-Member Beneficiary Form   PDF
Notice of Claim   PDF
Other Public Service Verification Form   PDF
Power of Attorney   PDF
Purchase Request Form   PDF
REAC Enrollment Form DocuSign  
Report a Death Form Web Form  
Request for Joinder Packet   PDF
Retired Member Beneficiary Designation Form   PDF
Retirement Estimate Request Form   PDF
SSA-44 Form (Medicare Income-Related Monthly Adjustment Form)   PDF
Survivor Continuance Recipient’s Designation of Beneficiaries Form   PDF
Tax Withholding Designation Form (IRS Federal Form W-4P) DocuSign PDF
Tax Withholding Designation Form (State of California) DocuSign PDF
Termination Election of Membership Request Form   PDF
Termination of Domestic Partnership   PDF
Verification of Enrollment Status   PDF
Via Benefits Reimbursement Forms Website  
Vision Plan Enrollment Form DocuSign PDF
VSP Reimbursement Forms: Login at VSP website Website