Forms

Overview

Forms

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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

Dental Plan Enrollment Form

Use this form to enroll in an ACERA dental plan.

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Medical Enrollment Form

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.

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Vision Plan Enrollment Form

Use this form to enroll in an ACERA vision plan.

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80% Authorization Form

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Active and Deferred Data Correction Form

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Active or Deferred Member Beneficiary Designation Form

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

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Affidavit of Dependent Eligibility

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Affidavit of Domestic Partnership

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Agreement and Order for Division of Retirement Benefits – Shared Records

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Agreement and Order for Division of Retirement Benefits – Separate Records

Download

Application For Disability Retirement (Sample Only)

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Application for Service Retirement

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

Aquilino Tier I Restoration Application

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Authorization for Release of Information and Documents

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Community Property Estimate Request Form

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Confidentiality Policy

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Declaration of Qualification for Registration as Domestic Partners

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Direct Deposit Form

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Health Fair Release Form

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HIPAA Authorization Form

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HIPAA Cancellation Form

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IRS Form W-9

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Medicare Part B Reimbursement Plan (MBRP) Application Form

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New Member Enrollment Questionnaire

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Non-Member Application for Retirement Allowance

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Non-Member Beneficiary Form

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Notice of Claim

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Via Benefits Reimbursement Forms
(Formerly OneExchange)

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

Other Public Service Verification Form

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Power of Attorney

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Purchase Request Form

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

Reimbursement Forms for Via Benefits Plans
(Formerly OneExchange)

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

Report a Death Form

Click here to report a death.

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Request for Joinder Packet

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Retired Member Beneficiary Designation Form

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Retirement Estimate Request Form

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

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Survivor Continuance Recipient’s Designation of Beneficiaries Form

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

For tips on filling out the federal withholding form, check out our flyer Helpful Hints: Federal Tax Withholding Form and Your Pension Check.

Download

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

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Termination Election of Membership Request Form

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Termination of Domestic Partnership

Download

Verification of Enrollment Status

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VSP Reimbursement Form

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