Forms

Overview

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Form DocuSign E-Form PDF Web Member Services
ACRE Enrollment Form   PDF  
Active or Deferred Member Beneficiary Designation Form   PDF  
Address and Name Change Form (Retirees, Payees, and Deferred Members) DocuSign PDF Log In
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  
Disability Website    
HIPAA Authorization Form   PDF  
HIPAA Cancellation Form   PDF  
IRS Form W-9 DocuSign 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 Form DocuSign 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 DocuSign PDF Log In
Purchase Request Form FAQ   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 DocuSign PDF Log In
Retirement Payment Option Addendum DocuSign 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 Log In
Tax Withholding Designation Form (State of California) DocuSign PDF Log In
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