Miscellaneous
PERS Residency Status Certification Form
to certify that you are or are not an Oregon state resident.
Information Change Request Form to
change your name, Social Security number, or address.
Direct deposit Set up
automatic deposit of your benefit payments.
Verification of Age List of acceptable documents for
verification of age, which is required before payment of distribution.
Police and
Fire Retiree Direct Insurance Premium Payment Election Form to withhold a specified portion of your
retirement benefit and use it to make direct payment of insurance premiums on your behalf.
Special Power of Attorney for
PERS This form gives the person(s) you designate the power to make any and all decisions for PERS-related
matters on your behalf.
Authorization to Release Account
Information This form allows you to authorize a third party to obtain information regarding your PERS
account or benefits.
Tax
W-4P Tier One/Tier Two/IAP Form to withhold income tax from
retirement benefit for Tier One/Tier Two/IAP members.
W-4P OPSRP Form to withhold income tax from retirement benefit
for OPSRP members.
W-8BEN Form to withhold income tax or claim treaty rights for
nonresident, non-U.S. citizen persons.
W-9 Required for any person with a foreign address.
W-4R IAP Rollover-eligible Distribution
Federal Tax Information and Acknowledgement
Tier One/Tier Two
Post-retirement
Beneficiary Designation For members who retired under the refund annuity or 15-year certain options or who
are receiving lump-sum installments. This election does not impact your Individual Account Program (IAP) beneficiary
designation.
Dispute Notice of Entitlement Tier
One/Tier Two Form to dispute the accuracy of information used in the computation of Tier One/Tier Two
retirement benefits.
Acknowledgment
of Potential Consequences Relating to Working After Retirement
OPSRP
Dispute Notice of Entitlement OPSRP
Form to dispute the accuracy of information used in the computation of OPSRP retirement benefits.
IAP
IAP Retirement Application For members who
have retired from Tier One/Tier Two or OPSRP but not the IAP.
IAP: Beneficiary
Nonspouse Rollover-eligible Distribution
Retirement Designation of
Beneficiary Packet For IAP retirees who elected an IAP installment plan upon retirement
IAP Dispute of Notice of
Distribution Form to dispute the accuracy of information used in the computation of the IAP distribution.
IAP Direct Transfer Rollover
Acceptance
IAP Rollover-eligible Distribution
Note:
View this webpage if you are already
receiving IAP installment payments and want to confirm which forms to turn in, if you are cashing out or rolling
over the remainder of your IAP balance.
Important information
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recent version of Adobe Reader.
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