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Retired member forms


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.


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


Dispute Notice of Entitlement OPSRP Form to dispute the accuracy of information used in the computation of OPSRP retirement benefits.


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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