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Member Forms: View, Print & Order
New: 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.

MBSClicking on this icon will direct you to log in to your Online Account.

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.

Select a Form according to its topic:
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Additional Contributions
Code Form Name Format Revised Info
AAA-T Additional Annuity Deposit-Traditional Pension Plan Contributors 03/2013 Learn More
VOL-MD Voluntary Deposit Form-Member-Directed Plan Participants 03/2013 Learn More
VOL-CO Voluntary Deposit Form-Combined Plan Participants 03/2013 Learn More


Beneficiary Designation
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


Change Request
Code Form Name Format Revised Info
F-50 Address/Bank/Name Change Request 03/2011 Learn More


College/Universities Only
Code Form Name Format Revised Info
A-4 ARP Application for a Transfer to an Alternative Retirement Plan (ARP) 03/2006 Learn More
ARP-3 Retirement Plan Election Form 10/2009 Learn More


Disability: More information regarding the disability program can be found on the Disability Benefits home page.
Code Form Name Format Revised Info
DR-APPLICATION
PACKET
Disability Benefit Application Packet

The purpose of this packet is to provide the necessary forms and information regarding applying for a disability benefit.

To see the list of information provided in this packet click the link above.
12/2013 Learn More
DR-APPLREQ Disability Benefits Appeal Request Form 04/2014 Learn More
F-6 Establishing Proof of Date of Birth and Proof of Legal Name Change 04/2013 Learn More
IT-4P Recipient's Withholding Certificate for Ohio Personal Income Tax 03/2008 Learn More
W-4P Federal Withholding Certificate for Pension or Annuity Payments 2014 Learn More
DR-VOLREQPUB Volunteer Service with Public Employer Request Form 09/2013 Learn More


Elected Official
Code Form Name Format Revised Info
CSH-6 Certification of Denied In-term Salary Increase 07/2005 Learn More


Health Care
Code Form Name Format Revised Info
HC-1G Health Care Coverage Application/Waiver of Coverage
• Form Instructions
Print 12/2012 Learn More


Membership
Code Form Name Format Revised Info
PED-1EE Independent Contractor/Employee Determination for Worker Print 07/2012 Learn More
PEDACKN Independent Contractor/Worker Acknowledgment Print 09/2013 Learn More
PEDREQ Notice of Right and Request for: Determination for OPERS Membership Print 03/2013 Learn More


Miscellaneous
Code Form Name Format Revised Info
DPO Division of Property Order 1/2014 Learn More
LL-2 Authorization for Release of Account Information 11/2012 Learn More


Re-employed Retiree
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 Refund Applications for Applicants Under Age 65 are submitted online. Please click here. 4/2011 Learn More
MP-1 Application For A Money Purchase Payment 08/2011 Learn More


Refund
Code Form Name Format Revised Info
AAA-4 Application For Additional Annuity Lump Sum Payment 4/2011 Learn More
  A-4CO Combined Plan refund applications are submitted online. Please click here. 4/2011 Learn More
  A-4MD Member-Directed Plan refund applications are submitted online. Please click here. 4/2011 Learn More
  A-4MP Lump Sum Money Purchase for Applicants Under Age 65 refund applications are submitted online. Please click here. 4/2011 Learn More
  A-4T Traditional Pension Plan refund applications are submitted online. Please click here. 4/2011 Learn More


Retirement
Code Form Name Format Revised Info
AAA-1 Application for Additional Annuity Retirement Benefit
. Form Instructions
08/2013 Learn More
CR-1 Application for Conversion Retirement Benefit
. Form Instructions
08/2013 Learn More
F-6 Establishing Proof of Date of Birth and Proof of Legal Name Change 04/2013 Learn More
HC-1G Health Care Coverage Application/
Waiver of Coverage

• Form Instructions
04/2012 Learn More
IT-4P Recipient's Withholding Certificate for Ohio Personal Income Tax -- Learn More
NLA-1 Election of Monthly or Lump Sum Payment for Non-Law Enforcement Service
• Form Instructions
(Note: For Law Enforcement Officers Only)
08/2013 Learn More
SR-1CO Combined Plan Retirement Application
• Form Instructions
documents to provide Document list to provide with this form
Print 08/2013 Learn More
SR-1MD Member-Directed Plan Retirement Application
• Form Instructions
documents to provideDocument list to provide with this form
08/2013 Learn More
  SR-1T Traditional Pension Plan Application -- Traditional retirement applications are submitted online. Please click here. If you are combining your service with another retirement system or have any questions, you may call OPERS for additional assistance.
documents to provide Document list to provide with application
10/2012 Learn More
SR-1T Change* Change to Partial Lump Sum Option Payment Amount or Retirement Plan Options
• Form Instructions
(*Note: Only for changes when first applying for retirement)
08/2013 Learn More
SR-6 Notice of Re-employment of an OPERS Benefit Recipient 09/2012 Learn More
SR-6E Notice of Re-employment of a Retired Elected or Appointed Official to an Elected Position 09/2012 Learn More
W-4P Federal Withholding Certificate for Pension or Annuity Payments 2012 Learn More


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


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
* Full Name:
* Street Address:
* City:
* State:
* Zip:
Daytime Phone (with area code):

  Please indicate your status:
OPERS Member Disability Benefit Recipient
OPERS Retiree Other   
Survivor Benefit Recipient  

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