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Employer Forms
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Fill-in Forms

You can now type directly onto a form. OPERS has begun switching its 'print-only' forms to a 'fill-in' format. While most OPERS forms are now fill-in, there are still some which are 'print-only.' The two formats are distinguishable by the 'P' or 'F' icon located directly next to the form name below.

This form is available in the 'print-only' format.

This form is available in the 'fill-in' format. You can type directly onto the form, print it, sign it and send it to OPERS. Or, you can print it out to be completed by hand.

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OPERS forms for employers are available for immediate use by clicking on the name of the publication listed below. We encourage you to request forms to be mailed to you if printing a form is not possible. The forms you request will be mailed within 3-5 business days.

All forms are available in PDF format PDF unless otherwise denoted at the form listing. If you have trouble viewing a PDF, then please visit the help page for assistance.

Feedback: Questions About Employer Forms

Please e-mail us with any issues or suggestions for Employer forms. Include your employer name, contact name, phone number and e-mail address.

Select a Form according to its topic:
Additional Contributions
Quantity Code Form Name Format Revised Info
AAA-T Additional Annuity Deposit-Traditional Pension Plan Contributors 01/2014 Learn More
VOL-MD Voluntary Deposit Form-Member-Directed Plan Participants 01/2015 Learn More
VOL-CO Voluntary Deposit Form-Combined Plan Participants 01/2015 Learn More


Beneficiary Designation
Quantity Code Form Name Format Revised Info
A-3U Designation of Beneficiary for Traditional Pension, Combined and Member-Directed Plans
• Form Instructions
10/2013 Learn More
A-3AA Member Designation of Beneficiary for Additional Annuity Account
• Form Instructions
06/2012 Learn More
A-3MP Designation of Beneficiary for Money Purchase Contributor
• Form Instructions
06/2012 Learn More
DBO-3CO Designation of Beneficiary for Lump Sum Death Benefit: For Combined Plan
• Form Instructions
08/2013 Learn More
DBO-3T Designation of Beneficiary for Lump Sum Death Benefit: For Traditional Pension Plan
• Form Instructions
08/2013 Learn More
GA-3 Designation of Beneficiary of Guaranteed Account by Retiree
• Form Instructions
08/2013 Learn More


Change Requests
Quantity Code Form Name Format Revised Info
F-50 Address/Bank/Name Change Request 10/2014 Learn More


College/Universities Only
Quantity Code Form Name Format Revised Info
A-4ARP Application for a Transfer to an Alternative Retirement Plan (ARP) 03/2006 Learn More
ARP-3 Retirement Plan Election Form 10/2014 Learn More
F-3 Request for Optional Exemption as a Student
• Form Instructions
10/2013 Learn More


Disability
More information regarding the disability program can be found on the Disability Benefits home page and the Employers Page.
Quantity Code Form Name Format Revised Info
DR-4 Report of Employer for Disability Applicant 04/2014 Learn More


Elected Officials
Quantity Code Form Name Format Revised Info
CSH-6 Certification of Denied In-term Salary Increase 04/2005 Learn More


Employer Reporting
Quantity Code Form Name Format Revised Info
E-3 Employer Payment Remittance Advice 12/2008 Learn More
F-103 Employer Request for Return of Unauthorized Contributions 08/2014 Learn More
  4710 For ECS reporting employers, please submit a Report of Retirement Contributions electronically on ECS. For employers who are not registered for ECS, please call Employer Outreach at 888-400-0965 to order more forms. 01/2011
  4710-2 For ECS reporting employers, please submit a Report of Retirement Contributions - Supplemental electronically on ECS. For employers who are not registered for ECS, please call Employer Outreach at 888-400-0965 to order more forms. 01/2011
  4710-3 For ECS reporting employers, please submit a Report of Service Purchase Deductions electronically on ECS. For employers who are not registered for ECS, please call Employer Outreach at 888-400-0965 to order more forms. 01/2011
CONVDOC Conversion Payment Template 10/2011 Learn More
NCL Non-Contributing List 12/2013


Employer Tools
Quantity Code Form Name Format Revised Info
INFO-EE OPERS A Tradition of Strength Employee Infographic 12/2013  
INFO-ER OPERS A Tradition of Strength Employer Infographic 12/2013  
MBREDOFF Educational Offerings for OPERS Members 06/2013  


Membership
Quantity Code Form Name Fillable Revised Info
PED-1ER Independent Contractor/Employee Determination for Employer 01/2013 Learn More
PEDACKN Independent Contractor/Worker Acknowledgment Fill In 06/2015 Learn More


New Employee
Quantity Code Form Name Format Revised Info
  A For ECS reporting employers, please submit personal history records electronically on ECS. For employers who are not registered on ECS, please call Employer Outreach at 1-888-400-0965 to order more forms. --- Learn More
F-3 Request for Optional Exemption as a Student
(College/Universities only)

• Form Instructions
10/2013 Learn More


Re-employed Retiree
Quantity Code Form Name Format Revised Info
A-3MP Designation of Beneficiary for Money Purchase Contributor
• Form Instructions
06/2012 Learn More
  A-4MP Lump Sum Money Purchase for Applicants Under Age 65 refund applications are submitted online. Please click here. 4/2011
MP-1 Application For A Money Purchase Payment 01/2015 Learn More


Refunds
Quantity Code Form Name Format Revised Info
A-4 ARP Application for a Transfer to an Alternative Retirement Plan (ARP)
(Colleges/Universities only)
05/2009 Learn More
  A-4CO Combined Plan refund applications are submitted online through MBS. Please direct the member to MBS. 4/2011 Learn More
  A-4MD Member-Directed Plan refund applications are submitted online through MBS. Please direct the member to MBS. 4/2011 Learn More
  A-4MP Lump Sum Money Purchase for Applicants Under Age 65 refund applications are submitted online through MBS. Please direct the member to MBS. 4/2011 Learn More
  A-4T Traditional Pension Plan refund applications are submitted online through MBS. Please direct the member to MBS. 4/2011 Learn More


Retirement
Quantity Code Form Name Format Revised Info
HC-1G Health Care Coverage Application/Waiver of Coverage 12/2013 Learn More
SR-1CO Combined Plan Retirement Application
• Form Instructions
Document list to provide with this form
Print 01/2013 Learn More
SR-1MD Member-Directed Plan Retirement Application
• Form Instructions
Document list to provide with this form
Print 01/2013 Learn More
  SR-1T Service Retirement Traditional Plan Application - Traditional retirement applications are submitted online through MBS. Please direct the member to MBS. If the member is combining their time with another retirement system or has questions, please have the member contact OPERS for additional assistance. 10/2012 Learn More
SR-6 Notice of Re-employment of an OPERS Benefit Recipient 06/2015 Learn More
SR-6E Notice of Re-employment of a Retired Elected or Appointed Official to an Elected Position 06/2015 Learn More


Service Credit
Quantity Code Form Name Format Revised Info
AA Certification of Unreported Public Service 05/2004 Learn More
IM-1 Certification of Interrupted Military Service Print 01/2013 Learn More
LOA Certification of Leave of Absence Print 08/2012  
OS-1 Certification of Federal, Out-of-state, or Municipal Service Print 08/2013 Learn More


Posters
Quantity Code Form Name Format Revised Info
2014MAPRET 2014 Map Out Your Retirement Poster 03/2014  
2014BDELEC 2014 OPERS Board of Trustees Election Poster 06/2014  


Forms to be mailed to

Please fill out the form below in order to have a form(s) mailed to you. The name and address information you enter will be used exactly as you enter it to create your mailing label, so please be sure to enter the data accurately.

  * required fields
* First Name: MI:
* Last Name:
* Employer Name:
* Street Address:
(Do not use a PO Box)

* City: State:

* Zip:

* Phone:

E-Mail:
Form Name Report of Retirement Contributions - Supplemental PDF
Form Code 4710-2
Last Revised Date 01/2011
Next Revision Date None expected at this time
DESCRIPTION

This form is used to report additional earnable salary and retirement contributions due to a Annual Conversion Payment, Payment to Terminated or Deceased Employee, Retroactive Salary Increase, Disability Pay or Settlement Agreement. Specific, supporting documentation that includes the date of payment of the additional earnable salary as well as payroll period(s) covered must be submitted when the supplemental form is used. Refer to the instructions attached to the form for the documentation that may be required for each reason.

Form Name Member Designation of Beneficiary for Additional Annuity Account PDF
Form Code A-3AA
Last Revised Date 06/2012
Next Revision Date None expected at this time
DESCRIPTION
This form is used to designate a beneficiary for a contributor to an Additional Annuity. The member contributing to this account would complete this form.
Form Name Member Designation of Beneficiary for Additional Annuity Account PDF
Form Code A-3AA
Last Revised Date 06/2012
Next Revision Date None expected at this time
DESCRIPTION
This form is used to designate a beneficiary for a contributor to an Additional Annuity. The member contributing to this account would complete this form.
Form Name Designation of Beneficiary for Money Purchase Contributor PDF
Form Code A-3MP
Last Revised Date 06/2012
Next Revision Date None expected at this time
DESCRIPTION
This form is used to designate a beneficiary for a contributor of to Money Purchase Annuity. The member contributing into this account would complete this form.
Form Name Designation of Beneficiary for Traditional Pension, Combined and Member-Directed Plans PDF
Form Code A-3U
Last Revised Date 10/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to designate a beneficiary for a member participating in the Traditional Pension, Combined and Member-Directed Plans. The member participating in these plans would complete this form.
Form Name Application for a Transfer to an Alternative Retirement Plan (ARP) PDF (Colleges/Universities only)
Form Code A-4 ARP
Last Revised Date 03/2006
Next Revision Date None expected at this time
DESCRIPTION
This form is used when a member has selected the Alternative Retirement Plan (ARP) and would like to transfer any contributions that were submitted to OPERS prior to the member electing the ARP plan. The member and the employer should complete the form. The employer needs to complete Section 3 only.
Form Name Certification of Unreported Public Service PDF
Form Code AA
Last Revised Date 05/2004
Next Revision Date None expected at this time

DESCRIPTION
This form is used to document any unreported service to OPERS. The employer and/or member complete the form.
Form Name Application for Additional Annuity Retirement Benefit PDF
Form Code AAA-1
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to annuitize a Traditional Pension Plan member's additional annuity account at the time of an age and service retirement or a money purchase annuity. The member completes the form and must sign in the presence of a Notary. If applicable, the spouse must also sign the form in the presence of a Notary.
Form Name Additional Annuity Benefit Pop Down Request PDF
Form Code AAA-1PD
Last Revised Date 08/2013
Next Revision Date None expected at this time

DESCRIPTION
This form is used by retirees who are receiving a monthly Additional Annuity under the Single Life Benefit (Plan B) and who later marry or remarry and wish to change their plan of payment to provide benefits for their new spouse. This form must be completed and signed in the presence of a Notary. Proof of date of birth and marriage also must be submitted. In the event the retiree's death occurs during the month OPERS receives the valid form, the change will not take effect and the benefits will cease. If the monthly benefit falls below $25.00 (for member or spouse) the plan of payment cannot be changed or a different plan can be chosen if the benefit would be at least $25.00.
Form Name Additional Annuity Benefit Pop Up Request PDF
Form Code AAA-1PU
Last Revised Date 08/2013
Next Revision Date None expected at this time

DESCRIPTION
If you have selected a joint and survivor annuity payment plan with your spouse as beneficiary and there is a divorce, annulment, or marriage dissolution, you may have your allowance re-calculated under a single life annuity (Plan B), if the court or your former spouse permits the change. The Plan B payment would be effective the first of the month following OPERS' receipt of this form. Please include a certified copy of your divorce, dissolution, or annulment decree, including any separation agreement.
Form Name Additional Annuity Benefit Pop Up Request - Plan F only PDF
Form Code AAA-1PUF
Last Revised Date 08/2013
Next Revision Date None expected at this time

DESCRIPTION
If you are receiving a joint and survivor annuity benefit under Life with Multiple Survivors (Plan F) and designated your spouse as one of your beneficiaries, use this form to cancel benefits to that spouse when your marriage is terminated by divorce, dissolution or annulment following your designation.
Form Name Designation of Beneficiary of Additional Annuity Account by Retiree/Contributor PDF
Form Code AAA-3GA
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
Retirees or contributors receiving an additional annuity benefit under a Single Life Benefit (Plan B) or Life with Fixed Period (Plan E), who wish to designate a new beneficiary to receive any remaining balance of the additional annuity account, should complete this form.
Form Name Application for Additional Annuity Lump Sum Payment PDF
Form Code AAA-4
Last Revised Date 2014
Next Revision Date None expected at this time

DESCRIPTION
This form is used to request a lump sum withdrawal of additional annuity deposits. The Traditional Pension Plan member would complete this form.
Form Name Additional Annuity Deposit-Traditional Pension Plan Contributors PDF
Form Code AAA-T
Related Educational Seminars https://www.opers.org/members/seminars/
Last Revised Date 01/2015
Next Revision Date Updated Annually

DESCRIPTION

This form is for Money Purchase Plan contributors who would like to make a voluntary deposit into their Additional Annuity account. It includes information about Internal Revenue Code limitations and how they may affect the deposits. OPERS requires this form since it is an agreement that the individual understands how the voluntary deposit is treated.

Members in the Member-Directed Plan or Combined Plan are required to complete either the Voluntary Deposit Form-Member-Directed Plan Participants (VOL-MD) or the Voluntary Deposit Form-Combined Plan Participants (VOL-CO) to make voluntary deposits to individual defined contribution accounts.

Form Name Retirement Plan Election Form PDF
(Colleges/Universities only)
Form Code ARP-3
Last Revised Date 08/2014
Next Revision Date None expected at this time

DESCRIPTION

This form is used by full-time employees of colleges or universities hired after August 1, 2005 to make an election between becoming a member of an Ohio Retirement System or an alternative retirement plan (ARP). The form must be completed and returned to the Human Resources Department of the college or university within 120 days of the employee’s hire date or transfer date into a full-time position.

Employee’s who do not elect to participate in an ARP or do not return the form within the prescribed time period will be enrolled in the applicable state retirement system. Once an alternative retirement plan is selected, the election is irrevocable. This form must be signed and dated by the member, certified by the employer and returned to OPERS.

Form Name Conversion Payment Template PDF
Form Code CONVDOC
Last Revised Date 12/2010
Next Revision Date None expected at this time
DESCRIPTION
This form is used to provide the specific, supporting documentation needed when reporting an OPERS-approved Conversion Plan payment. Completion of the form is required when a Report of Retirement Contributions – Supplemental (form 4710-2) is submitted with a reason of “Conversion Plan Payment”.
Form Name Application for Conversion Retirement Benefit PDF
Form Code CR-1
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to apply for a Traditional Pension Plan member's age and service retirement benefit after the member's disability benefit has ended. This applies only to the Revised Disability plan. The member completes the form and must sign in the presence of a Notary. If applicable, the spouse must also sign the form in the presence of a Notary.
Form Name Certification of Denied In-term Salary Increase PDF
Form Code CSH-6
Last Revised Date 07/2005
Next Revision Date None expected at this time
DESCRIPTION
This form should be completed by public officials who are contributing to OPERS and are constitutionally prohibited from receiving an in-term salary increase and wish to contribute on the full amount of their salary had they not been denied the increase. The form must be signed by the member and certified by the employer.
Form Name Designation of Beneficiary for Lump Sum Death Benefit: For Combined Plan PDF
Form Code DBO-3CO
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to designate a different beneficiary(ies) to receive the lump sum death benefit for a retiree's benefit under the defined benefit portion of the Combined Plan. The member completes the form and must sign in the presence of two witnesses. These two witnesses also must sign the form and cannot be the designated beneficiary.
Form Name Designation of Beneficiary for Lump Sum Death Benefit: For Traditional Pension Plan PDF
Form Code DBO-3T
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to designate a different beneficiary(ies) to receive the lump sum death benefit for a retiree's age and service or disability benefit under the Traditional Pension Plan. The member completes the form and must sign in the presence of two witnesses. These two witnesses also must sign the form and cannot be the designated beneficiary.
Form Name Division of Property Order PDF
Form Code DPO
Last Revised Date 4/2015
Next Revision Date None expected at this time
Special Note This form will remain in a print-only format.
DESCRIPTION

The Division of Property Order form, adopted by Ohio Administrative Rule 145-1-72, is the standard form for a court order, as specified in Sections 3105.80 to 3105.90, Ohio Revised Code, that permits Ohio PERS to make payments to a member's former spouse for the purpose of dividing a benefit or refund upon the termination of a member's marriage and upon the member's receipt of a benefit or refund. The standard DPO form is used by all five Ohio retirement systems, including Ohio PERS.

If you have questions filling out this form, please contact an OPERS Customer Service Representative toll-free at 1-800-222-PERS (7377) to have your questions directed to Legal Services.

Form Name Disability Benefits Appeal Request Form PDF
Form Code DR-APPLREQ
Last Revised Date 04/2014
Next Revision Date None expected at this time

DESCRIPTION

This form is used to file an appeal of the Retirement Board’s denial or termination of an applicant's disability benefit. In addition the form can be used to request an extension of the appeal time frame. Along with this form members are required to submit the "Attending Physician Statement" (DR-APS) and additional objective medical evidence.

Form Name Report of Physician PDF
Form Code DR-APS
Last Revised Date 05/2014
Next Revision Date None expected at this time
DESCRIPTION
This form is used to compile specific medical information in regard to the condition(s) that render the applicant permanently disabled from the duties of their past public employment. The physician that is treating the applicant for the disabling condition(s) should complete this form. This form is utilized in instances of New Applications, Annual Review, Benefit Termination and Appeal requests.
Form Name Disability Continued Medical Treatment Form PDF
Form Code DR-CMT
Last Revised Date 04/2014
Next Revision Date None expected at this time
DESCRIPTION
A medical form to be completed by a benefit recipient’s treating physician for compliance with the Continued Medical Treatment requirement.
Form Name Disability Benefit Termination Request Form PDF
Form Code DR-SELFTERMREQ
Last Revised Date 04/2014
Next Revision Date None expected at this time
DESCRIPTION
This form is to be completed by a disability benefit recipient who wishes to terminate his/her disability Benefit and also requires a submission of an Attending Physician Statement (DR-APS) and objective medical evidence supporting his/her claim.
Form Name Volunteer Service with Public Employer Request Form PDF
Form Code DR-VOLREQPUB
Last Revised Date 09/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is to be completed by a disability benefit recipient who wishes to terminate his/her disability Benefit and also requires a submission of an Attending Physician Statement (DR-APS) and objective medical evidence supporting his/her claim.
Form Name Disability Benefit Application PDF
Form Code DR-1
Last Revised Date 07/2015
Next Revision Date None expected at this time
DESCRIPTION
This form is used to compile personal information regarding the person who is making application for disability benefit. The purpose is to gather as much up-front, pertinent information to alleviate the need to make requests at a later date, thus avoiding delay and minimizing process time. The form seeks information such as address, bank, condition that necessitates applying for a disability retirement and information regarding service covered under another retirement system. The person applying for a disability benefit should complete this form.
Form Name Request for Review of Employment from a Disability Benefit RecipientPDF
Form Code DR-2
Last Revised Date 04/2014
Next Revision Date None expected at this time
DESCRIPTION
This form may be used by a disability benefit recipient seeking private employment. The purpose of the form is to give OPERS a clear picture of what duties may be performed in a recipient's prospective employment. Since a disability benefit is based on a member being incapable of performing the duties of their most recent public employment, this formal request will enable OPERS to make an accurate assessment and possibly prevent a recipient from jeopardizing the receipt of a disability benefit. After completion and submission to OPERS, we will review the request and let you know if such employment may be permitted.
Form Name Report of Employer for Disability Applicant PDF
Form Code DR-4
Last Revised Date 04/2014
Next Revision Date None expected at this time
DESCRIPTION
This form is used to compile information from the applicant’s most recent public employer. Specifically, it seeks information about the applicant’s job title and duties, final date of compensation and retirement deductions.
Form Name Disability Benefit Application Packet
Form Code Disability Benefit Application Packet
Last Revised Date N/A
Next Revision Date None expected at this time
DESCRIPTION
The purpose of this packet is to provide the necessary forms and information regarding applying for a disability benefit. Submission of all packet documentation is essential in processing your disability benefit application.
Form Name Disability Continued Treatment Attending Physician Statement PDF
Form Code DRCT-APS
Last Revised Date 04/2014
Next Revision Date None expected at this time
DESCRIPTION
The Recipient's attending physician should complete this form only if the recipient has worked with Managed Medical Review Organization (MMRo). This form should only be used if you are required to obtain continued treatment.
Form Name Disability Benefit Rehabilitative Services Selection Form PDF
Form Code DR-REHABSELECT
Last Revised Date 2015
Next Revision Date None expected at this time
DESCRIPTION
None at this time.
Form Name Employer Payment Coupon PDF
Form Code E-3
Last Revised Date 12/2008
Next Revision Date None expected at this time
DESCRIPTION
This coupon is used to communicate to OPERS how to apply employer payments against their OPERS account(s). The employer payroll or fiscal officers identified as authorized signers for the employer will complete this form.
Form Name Employer Request for Return of Unauthorized Contributions PDF
Form Code F-103
Last Revised Date 08/2014
Next Revision Date None expected at this time
DESCRIPTION
This form is used to return contributions to employers that have already been posted to a member's account. The contributions were remitted to OPERS in error, so they are returned as unauthorized. The employer payroll or fiscal officers identified as authorized signers for the employer will complete this form.
Form Name Request for Optional Exemption as a Student
(Colleges/Universities only)PDF
Form Code F-3
Last Revised Date 10/2013
Next Revision Date None expected at this time
DESCRIPTION
Students working at an educational institution, where they are also attending classes, use the form to exempt themselves from OPERS membership. The student, as well as the payroll or other fiscal officer identified as an authorized signer for the employer, will complete this form.
Form Name Address/Bank/Name Change Request PDF
Form Code F-50
Last Revised Date 10/2014
Next Revision Date None expected at this time
DESCRIPTION
A member uses this form to change their name and/or home address with Ohio PERS. A recipient receiving a monthly benefit may also use this form to change their banking information. This request cannot be processed without required supporting documentation and a signature.
Form Name Alternate Payee Address/Bank/Name Change Request PDF
Form Code F-50AP
Last Revised Date 10/2009
Next Revision Date None expected at this time
DESCRIPTION
An alternate payee receiving a monthly benefit uses this form to change their name, home address and/or banking information with OPERS. This request cannot be processed without required supporting documentation and a signature.
Form Name Establishing Proof of Date of Birth and Proof of Legal Name Change PDF
Form Code F-6
Last Revised Date 04/2013
Next Revision Date None expected at this time
Special Note This form will remain in a print-only format.
DESCRIPTION
This form lists the various documents acceptable by OPERS for proof of date of birth. This form is informational only. There is nothing to complete.
Form Name Designation of Beneficiary of Guaranteed Account by Retiree PDF
Form Code GA-3
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used for retirees who currently receive a benefit under the Plan B and/or Plan E plan of payment who wish to designate a new beneficiary. These retirees should fill out this form.
Form Name Designation of Beneficiary of Guaranteed Account by Combined Plan Retiree PDF
Form Code GA-3CO
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used by Combined Plan retirees who:
  • Have purchased service credit in the Combined Plan and are receiving a benefit for the defined benefit portion of their account under a Single Life Benefit (Plan B) or Life with Fixed Period (Plan E);
  • Or, they are receiving a monthly annuity from OPERS for all or some of the defined contribution portion of their account under Plan B or E;
  • Or, they have a balance remaining in their individual account with the DC plan administrator.
These retirees use this form to change the designated beneficiary(ies) to receive any remaining balance of the guaranteed account after their death.
Form Name Designation of Beneficiary of Guaranteed Account by Member-Directed Plan Retiree PDF
Form Code GA-3MD
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used by Member-Directed Plan retirees who have all or a portion of their Member-Directed Plan account annuitized under Single Life Benefit (Plan B) or Life with Fixed Period (Plan E) or they have any balance remaining in their individual account with the DC plan administrator. These retirees use this form to change the designated beneficiary(ies) to receive any remaining balance of the guaranteed account after their death.
Form Name Health Care Coverage Application/Waiver of Coverage
Form Code HC-1G
Last Revised Date 12/2013
Next Revision Date As needed.
DESCRIPTION
This is an application for OPERS health care coverage for Traditional Pension and Combind Plan benefit recipients. The information provided on this application will be used in determining your eligibility for health care coverage.
Form Name Voluntary Termination of Medical/Pharmacy Coverage
Form Code HCCANC
Last Revised Date 01/2014
Next Revision Date None at this time
DESCRIPTION
Use this form to waive your medical/pharmacy coverage or cancel dependent medical/pharmacy coverage. To waive your medical/pharmacy coverage, complete Sections 1 and 2. Please note that by waiving your medical/pharmacy coverage, your dependent(s) will not have coverage either. If you wish to cancel only dependent coverage, complete Sections 1 and 3. This completed form must be returned to OPERS.
Form Name Health Care Change Form
Form Code HCCHG
Last Revised Date 12/2013
Next Revision Date None at this time
DESCRIPTION
Use this Form to enroll your dependents in your health care plan outside of an open enrollment period. You may only enroll dependents outside of an open enrollment period if this form is completed and returned with the requested documentation within 60 days of one of the following qualifying events:
  • Birth or legal adoption of a child
  • Marriage
  • An eligible child becomes a qualifying student
  • You are required to provide coverage for a child pursuant to a National Medical Support Notice
  • Your eligible dependent has involuntarily lost health care coverage from another source. You must provide documentation from the other group plan confirming the termination date of his/her other coverage.
You may only enroll your dependent in the plan(s) in which you are presently covered.
Form Name Income Based Discount Program Application
Form Code HC-IBD
Last Revised Date 10/2013
Next Revision Date None expected at this time

DESCRIPTION
The OPERS Income Based Discount Program is designed to help qualified benefit recipients pay for their participation in the OPERS Medical/Pharmacy plan. Please note that the discount program does not apply to vision, dental or long term care coverage.

This program provides a 30 percent reduction in the premium amount you pay each month for medical/pharmacy coverage if your 2011 household income was equal to or less than 150 percent of the federal poverty level. Household income includes all income and wages you earned, plus the income and wages of your spouse and any dependent(s) you claimed on your 2011 federal income tax return.

If your gross income was below the federal filing threshold (see www.IRS.gov or your tax professional for these limits) and you are not required to file an income tax return, you may be eligible for this program.

Complete this application if you are eligible for the program.

Form Name HIPAA Authorization Form
Form Code HIPAA AUTH
Last Revised Date 10/2012
Next Revision Date None at this time

DESCRIPTION
Federal law prohibits the release of protected health information to a third party without the written authorization of the participant who is receiving health care coverage from OPERS. If an individual is receiving health care coverage from OPERS and would like to authorize a third party to receive personal health information related to the individual’s health care coverage, they must complete the HIPAA authorization form. The HIPAA authorization form will not authorize the release of confidential pension account information.

For release of confidential pension information, the member/recipient must complete the Authorization for Release of Account Information (LL-2).

Form Name Certification of Interrupted Military Service PDF
Form Code IM-1
Last Revised Date 01/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is to document the earnable salary the member would had earned in public service had the service not been interrupted by military service. Both the member and employer complete the form.
Form Name Recipient's Withholding Certificate for Ohio PERSonal Income Tax PDF
Form Code IT-4P
Last Revised Date 03/2008
Next Revision Date None expected at this time
DESCRIPTION
This form is used to initiate the addition and/or deletion of state of Ohio income tax withholding from monthly pension payments. Any retiree or recipient who is receiving a monthly pension payment who wants to have state of Ohio income tax withheld or removed from their payment would complete this form.
Form Name Authorization for Release of Account Information PDF
Form Code LL-2
Last Revised Date 11/2012
Next Revision Date None expected at this time

DESCRIPTION
Ohio law prohibits the release of confidential account information without the member’s written authorization. An individual uses this form to authorize a third party to request and receive information pertaining to the individual’s Ohio PERS pension account. This form will not authorize the release of protected health information related to a retiree or dependent’s health care coverage from OPERS. For release of protected health information, the retiree must complete the Authorization Form for Uses and Disclosures of Participant Protected Health Information (HIPAA AUTH).

If you have questions about filling out this form, please contact an OPERS Member Services Representative toll-free at 1-800-222-PERS (7377).

Form Name Application for a Money Purchase Payment PDF
Form Code MP-1
Last Revised Date 01/2015
Next Revision Date None expected at this time
DESCRIPTION
This form is used to apply for a monthly or lump sum money purchase payment. The re-employed retiree completes the form and must sign it in the presence of a Notary. If applicable, the spouse must also sign the form in the presence of a Notary. Also, the employer may certify the last day and contributions, but it is not necessary. OPERS will send out the appropriate form to the employer for completion.
Form Name Money Purchase Annuity Payment Pop Down Request
Form Code MP-1PD
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION

This form is used by retirees who are receiving a monthly Money Purchase Annuity under the Single Life Benefit (Plan B) and who later marry or remarry and wish to change their plan of payment to provide benefits for their spouse. The member and spouse must fill out and sign in the presence of a Notary. Proof of date of birth and marriage also must be submitted.

In the event the retiree's death occurs during the month OPERS receives the valid form, the change will not take effect and the benefits will cease. If the monthly benefit falls below $25 (for member or spouse) the plan of payment cannot be changed or a different plan can be chosen if the benefit would be at least $25.

Form Name Money Purchase Annuity Payment Pop Up Request PDF
Form Code MP-1PU
Last Revised Date 08/2013
Next Revision Date None expected at this time

DESCRIPTION
If you have selected a joint and survivor annuity payment plan with your spouse as beneficiary and there is a divorce, annulment, or marriage dissolution, you may have your money purchase payment re-calculated under a single life annuity (Plan B), if the court or your former spouse permits the change. The Plan B payment would be effective the first of the month following OPERS' receipt of this form. Please include a certified copy of your divorce, dissolution, or annulment decree, including any separation agreement.
Form Name Money Purchase Annuity Payment Pop Up Request - Plan F only PDF
Form Code MP-1PUF
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
If you are receiving a joint and survivor annuity benefit under Life with Multiple Survivors (Plan F) and designated your spouse as one of your beneficiaries, use this form to cancel benefits to that spouse when your marriage is terminated by divorce, dissolution or annulment following your designation.
Form Name Designation of Beneficiary by a Recipient Receiving a Money Purchase Annuity PDF
Form Code MP-3GA
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
Re-employed retirees receiving a monthly money purchase annuity under a Single Life Benefit (Plan B), who wish to designate a new beneficiary should complete this form.
Form Name Election of Monthly or Lump Sum Payment For Non-Law Enforcement Service PDF
(For Law Enforcement Officers Only)
Form Code NLA-1
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to apply for a lump sum or monthly benefit for the member's portion of non-law enforcement service that cannot be used in their law enforcement benefit calculation. The member completes the form and must sign in the presence of a Notary.
Form Name Certification of Federal, Out-of-state or Municipal Service PDF
Form Code OS-1
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to document out-of-state service, federal service, and Ohio municipal retirement system service for the purchase of additional service credit in OPERS. It is used to document whether this service was full-time and continuous service based on OPERS rules. Both the member and employer complete the form.
Form Name Independent Contractor/Employee Determination for Worker
Form Code PED-1EE
Last Revised Date 03/2015
Next Revision Date None expected at this time
DESCRIPTION
This form is used by OPERS to obtain information to determine whether a worker is a public employee for purposes of state retirement law. OPERS recognizes that, while questions in this form are asked in the past tense, you may be providing information on present service.
Form Name Independent Contractor/Employee Determination for Employer
Form Code PED-1ER
Last Revised Date 01/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used by OPERS to obtain information to determine whether a worker is a public employee for purposes of state retirement law. OPERS recognizes that, while questions in this form are asked in the past tense, you may be providing information on present service.
Form Name Independent Contractor/Worker Acknowledgment
Form Code PEDACKN
Last Revised Date 06/2015
Next Revision Date None expected at this time
DESCRIPTION
This form must be completed by any individual who begins providing personal services to a public employer on or after Jan. 7, 2013 but is not considered by the public employer to be a public employee and will not have contributions made to OPERS for the services.
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Form Name Service Purchase Funds Transfer PDF
Form Code SPFT
Last Revised Date 01/2012
Next Revision Date None expected at this time
DESCRIPTION
The form is used by members wishing to roll money into OPERS to purchase service credit. OPERS requires the form as a compliance issue so we are assured, by member's signature, that the money should be treated as a rollover. Any member wishing to roll money into OPERS to add to their Additional Annuity Account, to make additional contributions to their individual defined contribution account, should use the appropriate voluntary deposit form (AAA-T, VOL-CO, VOL-MD).
Form Name Combined Plan Retirement Application PDF
Form Code SR-1CO
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to apply for retirement benefits under both the defined benefit and defined contribution components of the Combined Plan. The member completes the form and must sign in the presence of a Notary. If applicable, the spouse must also sign the form in the presence of a Notary. The payroll officer will need to certify the last day the member will receive earnable salary and the last three payroll periods (if known) for the member submitting the form.
Form Name Member-Directed Plan Retirement Application PDF
Form Code SR-1MD
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION

This form is used to apply for a distribution under the Member-Directed Plan. The member completes the form and must sign in the presence of a Notary. If applicable, the spouse must also sign the form in the presence of a Notary. The payroll officer will need to certify the last day the member will receive earnable salary and the last three payroll periods (if known) for the member submitting the form.

Four of the distribution options offered are administered by a third-party administrator. If one of these options is selected, the member will receive additional information to initiate the distribution at the time the Application is approved. The fifth distribution option is administered by Ohio PERS.

Form Name Age & Service Retirement Benefit Pop Down Request PDF
Form Code SR-1PD
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION

This form is used by retirees who are receiving an age and service retirement benefit under the Single Life Benefit (Plan B) and who later marry or remarry and wish to change their plan of payment to provide benefits for their new spouse. The member and the spouse must fill out and sign in the presence of a Notary. Proof of date of birth and marriage also must be submitted. In the event the retiree's death occurs during the month OPERS receives the valid form, the change will not take effect and the benefits will cease.

If your effective benefit date was on or after Nov. 1, 2006, you are currently receiving an age and service retirement benefit under Life with Selected % to Survivor (Plan C) or Life with Multiple Survivors (Plan F), are court-ordered to designate one or more than one former spouse as a beneficiary and wish to designate your new spouse as beneficiary after marriage, do not use this form. Please contact OPERS for the proper form.

Form Name Age and Service Retirement Benefit Pop Down Request PDF
Form Code SR-1PDF
Last Revised Date 06/2007
Next Revision Date None expected at this time
DESCRIPTION

This form should be used by a benefit recipient whose effective benefit date was on or after Nov. 1, 2006, are currently receiving an age and service retirement benefit under Life with Selected % to Survivor (Plan C) or Life with Multiple Survivors (Plan F), are court-ordered to designate one or more than one former spouse as a beneficiary and wish to designate their new spouse as beneficiary after their marriage.

Form Name Age & Service Retirement Benefit Pop Up Request PDF
Form Code SR-1PU
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION

If you have selected a joint and survivor annuity payment plan at retirement with your spouse as beneficiary and there is a divorce, annulment, or marriage dissolution, you may have your retirement allowance re-calculated under a single life annuity (Plan B), if the court or your former spouse permits the change. The Plan B payment would be effective the first of the month following OPERS receipt of this form. Please include a certified copy of your divorce decree, dissolution decree, or annulment decree, including any separation agreement.

Form Name Age and Service Retirement Benefit Pop Up Request - Plan F only PDF
Form Code SR-1PUF
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
If you are receiving a joint and survivor annuity benefit under Life with Multiple Survivors (Plan F) and designated your spouse as one of your beneficiaries, use this form to cancel benefits to that spouse when your marriage is terminated by divorce, dissolution or annulment following your designation.
Form Name Change to Partial Lump Sum Option Payment Amount or Retirement Plan Options PDF
(Use only for changes when you first apply for retirement)
Form Code SR-1T Change
Last Revised Date 08/2013
Next Revision Date None expected at this time
DESCRIPTION
This form is used to change a member's plan of payment/beneficary information or PLOP prior to a retirement benefit being released or finalized. The form must be completed, by the member, in its entirety. If the member only wishes to change/choose PLOP options, they need to complete Sections 1, 3, 4 (for rollover), 5 (if married), and 6. If the member only wishes to change their plan of payment or beneficiary information, Sections 1, 2, 5 (if married and selecting a plan other than A), and 6 must be completed.
Form Name Notice of Re-employment of an OPERS Benefit Recipient
Form Code SR-6
Last Revised Date 06/2015
Next Revision Date None expected at this time
DESCRIPTION
This form is used to inform the Retirement System of an OPERS retiree's return to public service. The retiree and the employer should complete this form. Timely receipt of this form at OPERS is essential since the employer may be held liable for any overpayment of benefits resulting from untimely notice of a retiree’s re-employment.
Form Name Notice of Re-employment of a Retired Elected or Appointed Official to an Elected Position
Form Code SR-6E
Last Revised Date 06/2015
Next Revision Date None expected at this time
DESCRIPTION
This form is used to inform the retirement system of an OPERS retired elected official's return to an elected position. The retiree and the employer should complete this form.
Form Name Voluntary Deposit Form-Combined Plan Participants PDF
Form Code VOL-CO
Last Revised Date 01/2015
Next Revision Date Updated Annually
DESCRIPTION

This form is for Combined Plan Participants who would like to make a voluntary deposit into their individual OPERS account with a personal check, money order or cashier's check, or with an eligible rollover distribution. It includes information about Internal Revenue Code limitations and how they may affect the deposits. OPERS requires this form since it is an agreement that the individual understands how the voluntary deposit is treated.

Members in the Member-Directed Plan are required to complete the Voluntary Deposit Form-Member-Directed Plan Participants (VOL-MD) to make voluntary contributions to their individual defined contribution accounts. Members in the Traditional Pension Plan and Money Purchase Contributors are required to complete the Additional Annuity Deposit-Traditional Pension Plan Contributors (AAA-T).

Form Name Voluntary Deposit Form-Member-Directed Plan Participants PDF
Form Code VOL-MD
Last Revised Date 01/2015
Next Revision Date Updated Annually
DESCRIPTION

This form is for Member-Directed Plan Participants who would like to make a voluntary deposit into their individual OPERS account with a personal check, money order or cashier's check, or with an eligible rollover distribution. It includes information about Internal Revenue Code limitations and how they may affect the deposits. OPERS requires this form since it is an agreement that the individual understands how the voluntary deposit is treated.

Members in the Combined Plan are required to complete the Voluntary Deposit Form-Combined Plan Participants (VOL-CO) to make voluntary contributions to their individual defined contribution accounts. Members in the Traditional Pension Plan contributors are required to complete the Additional Annuity Deposit-Traditional Pension Plan Contributors (AAA-T) to deposit additional monies into a separate account.

Form Name Federal Withholding Certificate for Pension or Annuity Payments PDF
Form Code W-4P
Last Revised Date 01/2015
Next Revision Date None expected at this time
DESCRIPTION
This IRS form is used to initiate the addition and/or deletion of federal income tax withholding from monthly pension payments or lump sum pension payments. Any retiree or beneficiary of a retiree who will be receiving a distribution from OPERS, whether as a monthly payment or lump sum payment, would complete this form.