Forms

Overview

Forms

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

80% Authorization Form

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Active and Deferred Data Correction Form

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Active or Deferred Member Beneficiary Designation Form

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

Download

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 – Separate Records

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Agreement and Order for Division of Retirement Benefits – Shared 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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Dental Plan Enrollment Form

Use this form to enroll in an ACERA dental plan.

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Direct Deposit 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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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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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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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.

Download

Request for Joinder Packet

Download

Retired Member Beneficiary Designation Form

Download

Retirement Estimate Request Form

Download

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)

1/2/20 Update: The IRS has not issued a new W-4P withholding form for 2020 yet. Keep checking the IRS website for further updates.

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

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

1/2/20 Update: The state of California has not issued an updated Tax Withholding Designation Form DE 4P yet for 2020. Continue using the attached 2019 form, or check the state’s website for further updates. You can find the date at the bottom of the form in small print. If it says (12-18) it hasn’t been updated.

Download

Termination Election of Membership Request Form

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Termination of Domestic Partnership

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Verification of Enrollment Status

Post

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

Vision Plan Enrollment Form

Use this form to enroll in an ACERA vision plan.

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VSP Reimbursement Form

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