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PMRS Forms

We are currently in the process of reviewing and updating our forms and are working to increase the usability of each form by making them user-friendly. The term “user-friendly,” in this context, means that a user will be able to type information directly onto the form as accessed from our website.

- Completed Forms can be sent to the following email address: Ra-rscompletedforms@pa.gov
- User-friendly forms are marked below with a checkmark icon:This is a "user-friendly form". Enter information electronically then print and mail to PMRS.
- For detailed information about each form, press the icon "i" icon: Click this icon below for an explanation of that particular form.

Form/Publication File Size Description Download
Enrollment in Plan & Employee Personal Records
(PMRB-1) Member Enrollment Application
67K  This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB-1 A) Optional Membership
 67K  This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB-2) Nomination of Beneficiaries
153K  This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB 5-A) Notice of Demographic Change 76K  This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB 5-B) Notice of Service Record Change 76K  This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB-15) Voluntary Contribution Change 35K Click for explanation Download
(PMRB-26) Portability 12K Click for explanation Download
(PMRB-27) Authorization To Release Pension-Related Information 102K Click for explanation Download
Optional Election Membership 29K Click for explanation Download
Termination of Employment Other Than By Death
(PMRB-3)Termination of Service Notification 86K Click for explanation Download
(PMRB-4) Application For Return Of Contributions 454K Click for explanation Download
(PMRB-6) Lump-Sum Distribution Supplement 344K Click for explanation Download
(PMRB-8) Application For Retirement Benefits 216K Click for explanation Download
(PMRB-40) DROP - Deferred Retirement Option Plan 45K This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB-44) DROP - Deferred Retirement Option Plan 45K This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB-50) Retirement Benefits for Plans with Automatic Spouse's Death Benefits 183K Click for explanation Download
Disability Benefits

(PMRB-9) Employer's Statement Concerning Disability
Order this form from your employer or PMRS

 Click for explanation Contact Us
(PMRB-10) Applicant's Statement Concerning Disability
Order this form from your employer or PMRS		 Click for explanation
(PMRB-11) Disability Retirement Application
Order this form from your employer or PMRS		 Click for explanation
(PMRB-17) Medical Report and Review
Order this form from your employer or PMRS		 Click for explanation
Money
(PMRB-28) Direct Deposit of Annuity Payments 245K  This is a "user-friendly form". Enter information electronically then print and mail to PMRS.Click for explanation Download
(PMRB-20) Revenue Transmittal Form 60K This is a "user-friendly form". Enter information electronically then print and mail to PMRS.  Click for explanation Download
(W-4P) Withholding Certificate for Pension or Annuity Payments 112K This is a "user-friendly form". Enter information electronically then print and mail to PMRS.  Click for explanation Download
(W-4R) Withholding Certificate for Nonperiodic Payments and Eligible Rollover Distributions 92K This is a "user-friendly form". Enter information electronically then print and mail to PMRS.  Click for explanation Download
Miscellaneous Forms
(PMRB-21) Quarterly Report Form 48K Click for explanation Download
(PMRB-21a) Quarterly Report Form 48K Click for explanation Download
NEW (PMRB-30) Disclosures 69K Click for explanation Download
(SSA-1945) Statement Concerning Your Employment in a Job Not Covered by Social Security 407K Click for explanation Download
PMRS Standard Investment Managers Advisory Agreement 139K Click for explanation Download

If you have questions or comments regarding our forms, please call 717-787-2065 or email us at ra-staff@pa.gov. "PMRS does not run the state aid program. If you have questions or need assistance filing state aid forms, please contact the Auditor General's Municipal Pension Reporting Program at 717-787-3637 MPRP@PaAuditor.gov".