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Thursday, July 31, 2014
MERS Forms

Employee Forms

Whether you're naming a beneficiary, updating your address, applying for retirement or much more, you'll find all our Employee Forms here. Click the links on the left to view the forms specific to your MERS program. To view a list of all our MERS forms, click here.

Form # Name Product Audience
5 Membership Application Defined Benefit Employer, Employee
10 Transfer Of Contributions Within MERS Defined Benefit Plan (excluding Hybrid Benefit Program DB Component) Defined Benefit Employee
21 Defined Benefit Beneficiary Change Request Form Defined Benefit Employee
24 Refund Application Defined Benefit Employee
25 MERS Safe Harbor Explanation Defined Benefit Employee
26 Refund Application for Deceased Member's Contributions Defined Benefit Employee
27 Verification for the Crediting of Other Governmental Service Defined Benefit Employee
28 Application for Deferred Service Status Defined Benefit Employee
29a Application for Service Retirement Defined Benefit Employee
29b Employer's Certification of Termination of Employment for Retiring Member Defined Benefit Employee
29C Dual Certification For Re-Employed Retiree Defined Benefit Employee
29D Dual Certification For Voter-Elected Or Appointed Official Who Retired From And Is Re-Employed By The Same Municipality Defined Benefit Employee
30 Election of Retirement Allowance Option Defined Benefit Employee
31 Pension Recipient's Federal Income Tax Withholding Authorization Defined Benefit, Hybrid Employee, Retiree
F-31b Withholding Certificate for Michigan Pension or Annuity Payments Defined Benefit, Hybrid, Defined Contribution Retiree
32 Application for Retirement Allowance by Surviving Spouse or Child Defined Benefit Employee
33 Statement of Contingent Survivor Beneficiary Defined Benefit Employee
34 Statement of Beneficiary Defined Benefit Employee
35A Standard Participant Transfer Rules Defined Benefit Employee
35B Standard Transfer Member Certification for Same Employer Defined Benefit Employee
35C Alternative Transfer Member Certification for Same Employer Defined Benefit Employee
F-36 Electronic Funds Transfer – Direct Deposit Authorization Defined Benefit, Defined Contribution, 457, Hybrid Employee
37 Stop Payment Request Defined Benefit Employee
F-38 Certification of Qualified Fund Rollover to MERS Defined Benefit Employee
41 Option IV Beneficiary Change Request Defined Benefit Employee
42 DROP+ and Election Defined Benefit Employee
46 Affidavit Affirming Existence of Insurable Interest Defined Benefit Employee
51 Application for Disability Retirement Defined Benefit, Disability Employer, Employee
52 Limitation on Disability Benefits – Affidavit Defined Benefit Plan Employee
53 Physician's Statement Defined Benefit, Disability Employer, Employee
54 Psychiatric Medical Report Defined Benefit, Disability Employer, Employee
71 MERS Model DRO for Defined Benefit Defined Benefit Employee
72 MERS Model EDRO for Defined Benefit Defined Benefit Employee
75 MERS Model DRO for Defined Contribution Defined Contribution Employee
77 Reciprocal Retirement Act (“Act 88”) - Adopting Units Defined Benefit, Defined Contribution, Hybrid Employer, Employee
78 MERS Model DRO for HCSP Health Care Savings Program Employee
MD-001 Personal Information Defined Benefit, Defined Contribution, Health Care Savings Program, 457, Hybrid Employee
MD-002 Payroll/Investment Election Defined Contribution Employee
MD-003 Beneficiary Designation Defined Contribution Employee
MD-004 Incoming Direct Rollover Defined Contribution Employee
MD-005 Distribution/Direct Rollover Defined Contribution Employee
MD-006 Spousal Beneficiary Claim Request Defined Contribution Employee
MD-007 Non-Spousal Beneficiary Claim Request Defined Contribution Employee
MD-008 In-Service Withdrawal Request Defined Contribution Employee
MD-009 Required Minimum Distribution Request Defined Contribution Employee
MD-010 DC Loan Application Defined Contribution Employee
MD-102 HCSP Investment Election Health Care Savings Program Employee
MD-103 HCSP Beneficiary Designation Health Care Savings Program Employee
MD-302 Payroll/Investment Election Hybrid Employee
MD-303 Beneficiary Designation Hybrid Employee
MD-304 Incoming Direct Rollover Hybrid Employee
MD-400 457 Program Enrollment Kit 457 Employer, Employee
MD-402 Payroll/Investment Election 457 Employee
MD-403 Beneficiary Designation 457 Employee
MD-404 Incoming Direct Rollover 457 Employee
MD-405 Distribution/Direct Rollover 457 Employee
MD-406 Spousal Beneficiary Claim Request 457 Employee
MD-407 Non-Spousal Beneficiary Claim Request 457 Employee
MD-408 In-Service Withdrawal Request 457 Employee
MD-409 Required Minimum Distribution Request 457 Employee
MD-410 Loan Application 457 Employee
MD-412 Unforeseeable Emergency Withdrawals 457 Employee
MD-414 Contribution Catch Up 457 Employee
MD-415 Opt Out Refund 457 Employee
2527 Request for Absolute Assignment and Successor Owner Endorsement Stable Income Annuity Employee
5031 Substitute IRS Forms W-4P and W-9 Stable Income Annuity Employee
8513 Immediate Annuity Application Stable Income Annuity Employee
6146 Statement of Beneficiary Claim to Benefits Stable Income Annuity Employee
6304 Request for Change of Beneficiary Stable Income Annuity Employee
6614 Request for Contract Application Amendment Stable Income Annuity Employee
11426 Request for EFT of Annuity Payout Stable Income Annuity Employee
11436 Request for Change of EFT Annuity Payout Stable Income Annuity Employee
12213 Request For Rollover, Transfer or Exchange Stable Income Annuity Employee
12216 Acknowledgement of Suitability in an Annuity Purchase Stable Income Annuity Employee
12428 Request for Change to Annuity Policy Stable Income Annuity Employee
13018 Qualified Joint and Survivor Annuity Notice and Spousal Consent Stable Income Annuity Employee
13469 Stable Income Annuity Disclosure Stable Income Annuity Employee
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Disclaimer
The information contained in this Web site is being made available as a public service. The information is not intended to constitute legal or investment advice, or to replace official versions of that information. Benefit Estimates or Service Credit Purchase estimates requested through this Web site are not official descriptions of any benefits, and do not represent a promise by MERS to provide any benefit(s) to any person(s). No one can detrimentally rely upon the information provided in, or requested through this Web site. MERS reserves the right to correct any errors, and presents this information without warranties, express or implied, regarding the information?s accuracy, timeliness or completeness. If you believe the information is inaccurate, out-of-date, or incomplete, or if you have problems accessing or reading the information, please call MERS at 800.767.MERS (6377).