PERAC Administrator Forms

These forms are used by retirement system staff to process requests to the Public Employee Retirement Administration Commission.

Online Forms:

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In this list

Disability Forms for Administrators

2016 Annual Statement of Earned Income New Member Data (PDF 410.5 KB)

Accidental Disability Retirement Checklist (PDF 84.92 KB)

Disability Retiree Current Information Form (PDF 207.06 KB)

Disability Transmittal to the Commission (PDF 242.79 KB)

Notice of Retirement Board Action on Disability Application (PDF 211.39 KB)

Physician's Statement Pertaining to a Member's Disability Retirement Application (PDF 212.9 KB)

Request for Appointment of a Regional Medical Panel (PDF 200.32 KB)

Transmittal of Background Information to a Regional Medical Panel (PDF 175.8 KB)

General Membership Forms for Administrators

Notice to PERAC of the Granting of 12(2)(d) Benefits (PDF 82.65 KB)

Termination Retirement Transmittal (PDF 81.26 KB)

Compliance Forms for Administrators & Retirement Board Members

2017 Statement of Financial Interests (PDF 177.31 KB)

2017 Statement of Financial Interests Instructions for Fill-in Form (PDF 109.66 KB)

Board Change Form (PDF 142.55 KB)

PROSPER Individual Account Approval Application (PDF 205.17 KB)

Employer Forms

Employer's Request for Information (PDF 61.28 KB)

Employer's Shift Substitution Certification (PDF 103.64 KB)

Employer's Termination Retirement Certification (PDF 59.48 KB)

Employer Statement for Disability Retirement Application (PDF 196.46 KB)

Involuntary Retirement Application (PDF 162.17 KB)

Buyback Worksheets

Repayment Worksheets for Buybacks in 2018 (PDF 326.22 KB)

Repayment Worksheets for Buybacks in 2017 (PDF 388.56 KB)

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