Forms
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
PDF Forms
Some forms require Adobe Acrobat Reader (free).
- ACRE Enrollment Form
- Active or Deferred Member Beneficiary Designation Form
- Address and Name Change Form (Retirees, Payees, and Deferred Members)
- Affidavit of Domestic Partnership
- Application For Disability Retirement (Sample Only)
- Aquilino Tier 1 Restoration Application
- Community Property Estimate Request Form
- Confidentiality Policy
- Declaration of Qualification for Registration as Domestic Partners
- Direct Deposit Form
- HIPAA Cancellation Form
- IRS Form W-9
- Kaiser Permanente Senior Advantage (KPSA) Enrollment Form
- Medicare Part B Reimbursement Plan (MBRP) Application Form
- Member Enrollment Questionnaire
- 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
- 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
- Affidavit of Dependent Eligibility
- Application for Service Retirement
- Medical Plan Enrollment Form – Manual PDF
- Dental Plan Enrollment Form – Manual PDF
- Vision Plan Enrollment Form – Manual PDF
- Read more
Publications
Some documents on this site require the use of Adobe Acrobat Reader (free).
Disability
Disability Retirement Handbook
Disability Retirement Procedures
- Health Reimbursement Account (HRA) Summary Plan Description
- ACERA Law - List of CERL Statutes Relating to ACERA
- Living Trusts Presentation
- Power of Attorney Presentation
- Wills Presentation
- Participating Employers Handbook
- Age Factor Percentages Chart
- Retirement Simplified Flyer
- Medicare Part D Creditable Coverage Notice
- Making Your Via Benefits Medicare Reimbursements Easier
- Getting Your Affairs In Order
- 2021 Retiree Enrollment Guide
- 2022 Retiree Enrollment Guide
- Dissolution and Legal Separation Memo
- Read more