Forms

Overview

Submit These Web Forms In Your Account

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

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PDF Forms

Some forms require Adobe Acrobat Reader (free). 

80% Authorization Form
ACRE Enrollment Form
Active or Deferred Member Beneficiary Designation Form
Address and Name Change Form (Retirees, Payees, and Deferred Members)
Affidavit of Dependent Eligibility
Affidavit of Domestic Partnership
Agreement and Order for Division of Retirement Benefits – Separate Records
Agreement and Order for Division of Retirement Benefits – Shared Records
Application For Disability Retirement (Sample Only)
Application for Service Retirement
Aquilino Tier 1 Restoration Application
Authorization for Release of Information and Documents
Community Property Estimate Request Form
Confidentiality Policy
Data Correction Form (Active and Deferred Members)
Declaration of Qualification for Registration as Domestic Partners
Dental Enrollment Form
Direct Deposit Form
HIPAA Authorization Form
HIPAA Cancellation Form
IRS Form W-9
Kaiser Permanente Senior Advantage (KPSA) Enrollment Form
Medical Enrollment Form
Medicare Part B Reimbursement Plan (MBRP) Application Form
Member Enrollment Questionnaire
Multiple Continuance Beneficiary Addendum
Non-Member Application for Retirement Allowance
Non-Member Beneficiary Form
Notice of Claim
Other Public Service Verification Form
Power of Attorney
Purchase Request Form
REAC Enrollment Form
Report a Death Form
Request for Joinder Packet
Retired Member Beneficiary Designation Form
Retirement Estimate Request Form
SSA-44 Form (Medicare Income-Related Monthly Adjustment Form)
Survivor Continuance Recipient's Designation of Beneficiaries Form
Tax Withholding Designation Form (IRS Federal Form W-4P)
Tax Withholding Designation Form (State of California)
Termination Election of Membership Request Form
Termination of Domestic Partnership
Verification of Enrollment Status
Via Benefits Reimbursement Forms at viabenefits.com
Vision Plan Enrollment Form
VSP Reimbursement Form