Memorandum  #13: Updated Forms on the PERAC Website

Date: 03/02/2020
Referenced Sources: PERAC Website

PERAC Memo #13, 2019

Table of Contents

To All Retirement Boards:


TO:                  All Retirement Boards

FROM:           John W. Parsons, Esq., Executive Director

RE:                  Updated Forms on the PERAC Website

DATE:            March 2, 2020

We are pleased to release updated Beneficiary, Disability, Employer, and General Membership Forms. The following forms have been updated on our website:

Beneficiary Forms

  • Application for Member Survivor Benefits
  • Beneficiary Change Form
  • Beneficiary Selection Form
  • Beneficiary Selection Form (Option D) - this is a new form!
  • Notice of Election of Benefits under 12(2)(d)
  • Retirement Option Selection Form
  • Spousal Affidavit

Disability Forms

  • Disability Retirement Application
  • Involuntary Retirement Application
  • Authorization to Use or Disclose Protected Health Information
    • This form is included in the Application for Disability Retirement
  • Physician’s Statement 
  • Regional Medical Panel Certificate (fillable version available in PROSPER)
    • This form replaces the three presumptions certificates

Employer Forms

  • Employer’s Shift Substitution Certification
  • Employer’s Statement Pertaining to an Application for Disability Retirement

General Membership Forms

  • Retirement Application (Voluntary Superannuation)
  • Refund Application (Withdrawal of Accumulated Total Deductions)
  • New Member Enrollment Form
  • Special Tax Notice Regarding Lump Sum Distributions
  • Veterans’ Buyback Form

You can find a link to all the new forms on our website,, on the Recent Updates or Forms & Publications pages. All new forms will have a “last updated” date of February, 2020. If you click on a link to any of the above-named forms and still see the previous version or an earlier date, please refresh your browser by right clicking anywhere in your browser and then clicking reload or refresh. If you have links to our forms from your websites, please update those links now. 

The completion of this project would not have been possible without all of the feedback we received from the retirement community at various MACRS conferences or directly to our staff. We thank you for your continued commitment to the effective and equitable administration of pension benefits for the public employees of the Commonwealth. We anticipate that additional forms in need of update will be addressed going forward, following this process of participation.

Commission Members

Philip Y Brown, Esq., Chairman
Suzanne M. Bump
Kathleen M. Fallon
Kate Fitzpatrick
James M. Machado
Robert B. McCarthy
Jennifer F. Sullivan

Downloads   for #13: Updated Forms on the PERAC Website

Referenced Sources:

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