Tuesday, September 27, 2016
MERS Forms

MERS Forms

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Form # Product Name Audience myMers Info
73 457 MERS Model DRO for 457 Plan Employee more information

MERS Model DRO for 457 Plan

Form #: 73

Product: 457
Audience: Employee

MD-505 ISP ISP Distribution Form Employer more information

ISP Distribution Form

Form #: MD-505

Product: ISP
Audience: Employer

FN-003 Defined Contribution Plan, Hybrid, Health Care Savings Program, 457, Retiree Health Funding Vehicle, Investment Services Program ACH Debit Request - Automated Transfer Authorization Employer more information

ACH Debit Request - Automated Transfer Authorization

Form #: FN-003
Description:

Employer Form: Banking information for employer to set up ACH transfer authorization for MERS DC, 457, HCSP, RHFV, and ISP.


Product: Defined Contribution Plan, Hybrid, Health Care Savings Program, 457, Retiree Health Funding Vehicle, Investment Services Program
Audience: Employer

DB-002 Defined Benefit Defined Benefit Adoption Agreement Employer more information

Defined Benefit Adoption Agreement

Form #: DB-002

Product: Defined Benefit
Audience: Employer

DB-001b Defined Benefit Resolution Adopting The Municipal Employees' Retirement System Defined Benefit Plan Employer more information

Resolution Adopting The Municipal Employees' Retirement System Defined Benefit Plan

Form #: DB-001b

Product: Defined Benefit
Audience: Employer

DB-001a Defined Benefit Administrative Order Adopting The Municipal Employees' Retirement System Defined Benefit Plan Employer more information

Administrative Order Adopting The Municipal Employees' Retirement System Defined Benefit Plan

Form #: DB-001a

Product: Defined Benefit
Audience: Employer

None Group Life & Disability Insurance Accidental Dismemberment Claim Packet Employer more information

Accidental Dismemberment Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Disability Claim Packet Employer more information

Disability Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Request for Life Conversion Materials Employer more information

Request for Life Conversion Materials

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Life Insurance Portability Form Employer more information

Life Insurance Portability Form

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Waiver of Premium Claim Packet Employer more information

Waiver of Premium Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Accelerated Benefit Claim Packet Employer more information

Accelerated Benefit Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Life Insurance Benefits Claim Packet Employer more information

Life Insurance Benefits Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Application for Group Insurance with Under 25 Employees Employer more information

Application for Group Insurance with Under 25 Employees

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Application for Group Insurance with 25 Employees or Over Employer more information

Application for Group Insurance with 25 Employees or Over

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Medical History Statement Employer more information

Medical History Statement

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Group Life & Disability Insurance Life Insurance Enrollment and Change Employer more information

Life Insurance Enrollment and Change

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

RH-669 Retiree Health Funding Vehicle RHFV Uniform Resolution Employer more information

RHFV Uniform Resolution

Form #: RH-669

Product: Retiree Health Funding Vehicle
Audience: Employer

MD-170 Health Care Savings Program HCSP Participation Agreement Employer more information

HCSP Participation Agreement

Form #: MD-170

Product: Health Care Savings Program
Audience: Employer

MD-169 Health Care Savings Program HCSP Uniform Resolution Employer more information

HCSP Uniform Resolution

Form #: MD-169

Product: Health Care Savings Program
Audience: Employer

None Health Care Savings Program, Retiree Health Funding Vehicle HCSP & RHFV Restated MERS Trust Agreement Employer more information

HCSP & RHFV Restated MERS Trust Agreement

Form #: None

Product: Health Care Savings Program, Retiree Health Funding Vehicle
Audience: Employer

MD-100 Health Care Savings Program Health Care Savings Program Enrollment Kit Employer, Employee more information

Health Care Savings Program Enrollment Kit

Form #: MD-100

Product: Health Care Savings Program
Audience: Employer, Employee

MD-300 Hybrid Hybrid Enrollment Kit Employer, Employee more information

Hybrid Enrollment Kit

Form #: MD-300

Product: Hybrid
Audience: Employer, Employee

13018 Stable Income Annuity Qualified Joint and Survivor Annuity Notice and Spousal Consent Employee more information

Qualified Joint and Survivor Annuity Notice and Spousal Consent

Form #: 13018

Product: Stable Income Annuity
Audience: Employee

12428 Stable Income Annuity Request for Change to Annuity Policy Employee more information

Request for Change to Annuity Policy

Form #: 12428

Product: Stable Income Annuity
Audience: Employee

11436 Stable Income Annuity Request for Change of EFT Annuity Payout Employee more information

Request for Change of EFT Annuity Payout

Form #: 11436

Product: Stable Income Annuity
Audience: Employee

6614 Stable Income Annuity Request for Contract Application Amendment Employee more information

Request for Contract Application Amendment

Form #: 6614

Product: Stable Income Annuity
Audience: Employee

6304 Stable Income Annuity Request for Change of Beneficiary Employee more information

Request for Change of Beneficiary

Form #: 6304

Product: Stable Income Annuity
Audience: Employee

6146 Stable Income Annuity Statement of Beneficiary Claim to Benefits Employee more information

Statement of Beneficiary Claim to Benefits

Form #: 6146

Product: Stable Income Annuity
Audience: Employee

12999 Stable Income Annuity Stable Income Annuity Disclosure Member more information

Stable Income Annuity Disclosure

Form #: 12999

Product: Stable Income Annuity
Audience: Member

8513 Stable Income Annuity Stable Income Annuity Adoption Packet Employee more information

Stable Income Annuity Adoption Packet

Form #: 8513

Product: Stable Income Annuity
Audience: Employee

2527 Stable Income Annuity Request for Absolute Assignment and Successor Owner Endorsement Employee more information

Request for Absolute Assignment and Successor Owner Endorsement

Form #: 2527

Product: Stable Income Annuity
Audience: Employee

2160 Group Life & Disability Insurance Proposal Process & Data Checklist Employer more information

Proposal Process & Data Checklist

Form #: 2160

Product: Group Life & Disability Insurance
Audience: Employer

MD-474 457 457 Eligible Automatic Contribution Arrangement (EACA) Addendum Employer more information

457 Eligible Automatic Contribution Arrangement (EACA) Addendum

Form #: MD-474

Product: 457
Audience: Employer

MD-473 457 457 Employer Contribution Addendum Employer more information

457 Employer Contribution Addendum

Form #: MD-473

Product: 457
Audience: Employer

MD-470 457 457 Participation Agreement Employer more information

457 Participation Agreement

Form #: MD-470

Product: 457
Audience: Employer

MD-471 457 457 Loan Addendum Employer more information

457 Loan Addendum

Form #: MD-471

Product: 457
Audience: Employer

MD-469 457 457 Uniform Resolution Employer more information

457 Uniform Resolution

Form #: MD-469

Product: 457
Audience: Employer

MD-415 457 Opt Out Refund Employee more information

Opt Out Refund

Form #: MD-415

Product: 457
Audience: Employee

MD-414 457 Contribution Catch Up Employee more information

Contribution Catch Up

Form #: MD-414

Product: 457
Audience: Employee

MD-412 457 Unforeseeable Emergency Withdrawals Employee more information

Unforeseeable Emergency Withdrawals

Form #: MD-412

Product: 457
Audience: Employee

MD-410 457 Loan Application Employee more information

Loan Application

Form #: MD-410

Product: 457
Audience: Employee

MD-409 457 Required Minimum Distribution Request Employee more information

Required Minimum Distribution Request

Form #: MD-409

Product: 457
Audience: Employee

MD-408 457 In-Service Withdrawal Request Employee more information

In-Service Withdrawal Request

Form #: MD-408

Product: 457
Audience: Employee

MD-407 457 Non-Spousal Beneficiary Claim Request Employee more information

Non-Spousal Beneficiary Claim Request

Form #: MD-407

Product: 457
Audience: Employee

MD-406 457 Spousal Beneficiary Claim Request Employee more information

Spousal Beneficiary Claim Request

Form #: MD-406

Product: 457
Audience: Employee

MD-405 457 Distribution/Direct Rollover Employee more information

Distribution/Direct Rollover

Form #: MD-405

Product: 457
Audience: Employee

MD-404 457 Incoming Direct Rollover Employee more information

Incoming Direct Rollover

Form #: MD-404

Product: 457
Audience: Employee

MD-403 457 Beneficiary Designation Employee more information

Beneficiary Designation

Form #: MD-403

Product: 457
Audience: Employee

MD-402 457 457 Investment Change Participant more information

457 Investment Change

Form #: MD-402

Product: 457
Audience: Participant

MD-400 457 457 Program Enrollment Kit Employer, Employee more information

457 Program Enrollment Kit

Form #: MD-400

Product: 457
Audience: Employer, Employee

MD-304 Hybrid Incoming Direct Rollover Employee more information

Incoming Direct Rollover

Form #: MD-304

Product: Hybrid
Audience: Employee

MD-303 Hybrid Beneficiary Designation Employee more information

Beneficiary Designation

Form #: MD-303

Product: Hybrid
Audience: Employee

MD-103 Health Care Savings Program HCSP Beneficiary Designation Employee more information

HCSP Beneficiary Designation

Form #: MD-103

Product: Health Care Savings Program
Audience: Employee

MD-372 Hybrid Hybrid Conversion Addendum Employer more information

Hybrid Conversion Addendum

Form #: MD-372

Product: Hybrid
Audience: Employer

MD-371 Hybrid Hybrid Loan Addendum Employer more information

Hybrid Loan Addendum

Form #: MD-371

Product: Hybrid
Audience: Employer

MD-370 Hybrid Hybrid Plan Adoption Agreement Employer more information

Hybrid Plan Adoption Agreement

Form #: MD-370

Product: Hybrid
Audience: Employer

MD-369b Hybrid Administrative Order Adopting MERS Hybrid Employer more information

Administrative Order Adopting MERS Hybrid

Form #: MD-369b

Product: Hybrid
Audience: Employer

MD-369 Hybrid Resolution Adopting MERS Hybrid Plan Employer more information

Resolution Adopting MERS Hybrid Plan

Form #: MD-369

Product: Hybrid
Audience: Employer

MD-016 Defined Contribution MERS-to-MERS Service Verification Form Employee False more information

MERS-to-MERS Service Verification Form

Form #: MD-016

Product: Defined Contribution
Audience: Employee

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-010 Defined Contribution Defined Contribution Loan Application Employee more information

Defined Contribution Loan Application

Form #: MD-010

Product: Defined Contribution
Audience: Employee

MD-009 Defined Contribution Required Minimum Distribution Request Employee more information

Required Minimum Distribution Request

Form #: MD-009

Product: Defined Contribution
Audience: Employee

MD-008 Defined Contribution In-Service Withdrawal Request Employee more information

In-Service Withdrawal Request

Form #: MD-008

Product: Defined Contribution
Audience: Employee

MD-007 Defined Contribution Non-Spousal Beneficiary Claim Request Employee more information

Non-Spousal Beneficiary Claim Request

Form #: MD-007

Product: Defined Contribution
Audience: Employee

MD-006 Defined Contribution Spousal Beneficiary Claim Request Employee more information

Spousal Beneficiary Claim Request

Form #: MD-006

Product: Defined Contribution
Audience: Employee

MD-005 Defined Contribution Distribution/Direct Rollover Employee more information

Distribution/Direct Rollover

Form #: MD-005

Product: Defined Contribution
Audience: Employee

MD-004 Defined Contribution Incoming Direct Rollover Employee more information

Incoming Direct Rollover

Form #: MD-004

Product: Defined Contribution
Audience: Employee

MD-003 Defined Contribution Beneficiary Designation Employee more information

Beneficiary Designation

Form #: MD-003

Product: Defined Contribution
Audience: Employee

MD-002 Defined Contribution Defined Contribution Investment Change Employee True more information

Defined Contribution Investment Change

Form #: MD-002

Product: Defined Contribution
Audience: Employee

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-102 Health Care Savings Program Health Care Savings Program Investment Change Employee more information

Health Care Savings Program Investment Change

Form #: MD-102

Product: Health Care Savings Program
Audience: Employee

MD-001 Defined Benefit, Defined Contribution, Health Care Savings Program, 457, Hybrid Personal Information Employee more information

Personal Information

Form #: MD-001

Product: Defined Benefit, Defined Contribution, Health Care Savings Program, 457, Hybrid
Audience: Employee

MD-000 Defined Contribution Defined Contribution Enrollment Kit Employer, Employee more information

Defined Contribution Enrollment Kit

Form #: MD-000

Product: Defined Contribution
Audience: Employer, Employee

94 Defined Benefit, Defined Contribution, Hybrid Employer Resolution Establishing Uniform Transfer Provision Employer more information

Employer Resolution Establishing Uniform Transfer Provision

Form #: 94

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer

91 Defined Benefit, Defined Contribution Amortization Policy for Closed Divisions Within Open Municipalities Employer more information

Amortization Policy for Closed Divisions Within Open Municipalities

Form #: 91

Product: Defined Benefit, Defined Contribution
Audience: Employer

90 Defined Benefit, Hybrid Restated Policy for Closed Groups Employer more information

Restated Policy for Closed Groups

Form #: 90

Product: Defined Benefit, Hybrid
Audience: Employer

86 Defined Benefit, Hybrid MERS Enforcement Procedure for Prompt Reporting and Payment Employer more information

MERS Enforcement Procedure for Prompt Reporting and Payment

Form #: 86

Product: Defined Benefit, Hybrid
Audience: Employer

85 Defined Benefit, Defined Contribution Plan, Health Care Savings Program, 457 Customer Contact Employer more information

Customer Contact

Form #: 85

Product: Defined Benefit, Defined Contribution Plan, Health Care Savings Program, 457
Audience: Employer

79 Defined Benefit, Defined Contribution, Hybrid Resolution adopting Act 88 Employer more information

Resolution adopting Act 88

Form #: 79

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer

78 Health Care Savings Program MERS Model DRO for HCSP Employee more information

MERS Model DRO for HCSP

Form #: 78

Product: Health Care Savings Program
Audience: Employee

77 Defined Benefit, Defined Contribution, Hybrid Reciprocal Retirement Act (“Act 88”) - Adopting Units Employer, Employee more information

Reciprocal Retirement Act (“Act 88”) - Adopting Units

Form #: 77

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer, Employee

75 Defined Contribution MERS Model DRO for Defined Contribution Employee more information

MERS Model DRO for Defined Contribution

Form #: 75

Product: Defined Contribution
Audience: Employee

72b Defined Benefit MERS Procedure for Reviewing and Qualifying Eligible Domestic Relations Orders Employee more information

MERS Procedure for Reviewing and Qualifying Eligible Domestic Relations Orders

Form #: 72b

Product: Defined Benefit
Audience: Employee

72 Defined Benefit MERS Model EDRO for Defined Benefit Employee more information

MERS Model EDRO for Defined Benefit

Form #: 72

Product: Defined Benefit
Audience: Employee

71 Defined Benefit MERS Model DRO for Defined Benefit Employee more information

MERS Model DRO for Defined Benefit

Form #: 71

Product: Defined Benefit
Audience: Employee

N/A Defined Benefit, Defined Contribution, Hybrid, Health Care Savings Program, 457 Domestic Relations Order Qualification Fee Policy Employee more information

Domestic Relations Order Qualification Fee Policy

Form #: N/A

Product: Defined Benefit, Defined Contribution, Hybrid, Health Care Savings Program, 457
Audience: Employee

54 Defined Benefit, Disability Psychiatric Medical Report Employer, Employee more information

Psychiatric Medical Report

Form #: 54

Product: Defined Benefit, Disability
Audience: Employer, Employee

F-53 Defined Benefit, Disability Physician's Statement of Disability Employer, Employee more information

Physician's Statement of Disability

Form #: F-53

Product: Defined Benefit, Disability
Audience: Employer, Employee

52 Defined Benefit Plan Limitation on Disability Benefits – Affidavit Employee more information

Limitation on Disability Benefits – Affidavit

Form #: 52

Product: Defined Benefit Plan
Audience: Employee

51 Defined Benefit, Disability Application for Disability Retirement Employer, Employee more information

Application for Disability Retirement

Form #: 51

Product: Defined Benefit, Disability
Audience: Employer, Employee

F-48 Defined Benefit Alternate Payee (Former Spouse) Benefit Application Participant more information

Alternate Payee (Former Spouse) Benefit Application

Form #: F-48

Product: Defined Benefit
Audience: Participant

F-50 Defined Benefit; Hybrid Informed Consent and Authorization: Application for Disability Retirement Employee more information

Informed Consent and Authorization: Application for Disability Retirement

Form #: F-50

Product: Defined Benefit; Hybrid
Audience: Employee

42 Defined Benefit DROP+ and Election Employee more information

DROP+ and Election

Form #: 42

Product: Defined Benefit
Audience: Employee

41 Defined Benefit Option IV Beneficiary Change Request Employee more information

Option IV Beneficiary Change Request

Form #: 41

Product: Defined Benefit
Audience: Employee

F-38 Defined Benefit Certification of Qualified Fund Rollover to MERS Employee more information

Certification of Qualified Fund Rollover to MERS

Form #: F-38

Product: Defined Benefit
Audience: Employee

37 Defined Benefit Stop Payment Request Employee more information

Stop Payment Request

Form #: 37

Product: Defined Benefit
Audience: Employee

F-36 Defined Benefit, Hybrid Electronic Funds Transfer – Direct Deposit Authorization Employee more information

Electronic Funds Transfer – Direct Deposit Authorization

Form #: F-36

Product: Defined Benefit, Hybrid
Audience: Employee

35C Defined Benefit Alternative Transfer Member Certification for Same Employer Employee more information

Alternative Transfer Member Certification for Same Employer

Form #: 35C

Product: Defined Benefit
Audience: Employee

35B Defined Benefit Standard Transfer Member Certification for Same Employer Employee more information

Standard Transfer Member Certification for Same Employer

Form #: 35B

Product: Defined Benefit
Audience: Employee

F-32 Defined Benefit, Hybrid Defined Benefit Survivor Beneficiary Application Employee False more information

Defined Benefit Survivor Beneficiary Application

Form #: F-32

Product: Defined Benefit, Hybrid
Audience: Employee

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

F-31b Defined Benefit, Hybrid, Defined Contribution Withholding Certificate for Michigan Pension or Annuity Payments Employee False more information

Withholding Certificate for Michigan Pension or Annuity Payments

Form #: F-31b

Product: Defined Benefit, Hybrid, Defined Contribution
Audience: Employee

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

31 Defined Benefit, Hybrid Pension Recipient's Federal Income Tax Withholding Authorization Employee, Retiree more information

Pension Recipient's Federal Income Tax Withholding Authorization

Form #: 31

Product: Defined Benefit, Hybrid
Audience: Employee, Retiree

F-29c Defined Benefit, Hybrid Working in Retirement Certification Employee more information

Working in Retirement Certification

Form #: F-29c

Product: Defined Benefit, Hybrid
Audience: Employee

29 Defined Benefit Application for Defined Benefit Retirement Employee more information

Application for Defined Benefit Retirement

Form #: 29

Product: Defined Benefit
Audience: Employee

27 Defined Benefit; Defined Contribution, Hybrid Verification for the Crediting of Other Governmental Service Employee more information

Verification for the Crediting of Other Governmental Service

Form #: 27

Product: Defined Benefit; Defined Contribution, Hybrid
Audience: Employee

26 Defined Benefit Refund Application for Deceased Member's Contributions Employee more information

Refund Application for Deceased Member's Contributions

Form #: 26

Product: Defined Benefit
Audience: Employee

25 Defined Benefit Special Tax Notice ("Safe Harbor" Explanation) Employee more information

Special Tax Notice ("Safe Harbor" Explanation)

Form #: 25

Product: Defined Benefit
Audience: Employee

24 Defined Benefit Refund Application Employee more information

Refund Application

Form #: 24

Product: Defined Benefit
Audience: Employee

MD-072 Defined Contribution Defined Contribution Conversion Addendum Employer more information

Defined Contribution Conversion Addendum

Form #: MD-072

Product: Defined Contribution
Audience: Employer

MD-071 Defined Contribution MERS Loan Addendum Employer more information

MERS Loan Addendum

Form #: MD-071

Product: Defined Contribution
Audience: Employer

MD-070 Defined Contribution MERS Defined Contribution Plan Adoption Agreement Employer more information

MERS Defined Contribution Plan Adoption Agreement

Form #: MD-070

Product: Defined Contribution
Audience: Employer

MD-069b Defined Contribution Administrative Order Adopting the MERS Defined Contribution Plan Employer more information

Administrative Order Adopting the MERS Defined Contribution Plan

Form #: MD-069b

Product: Defined Contribution
Audience: Employer

MD-069 Defined Contribution Resolution Adopting the MERS Defined Contribution Plan Employer more information

Resolution Adopting the MERS Defined Contribution Plan

Form #: MD-069

Product: Defined Contribution
Audience: Employer

21 Defined Benefit Defined Benefit Beneficiary Change Request Form Employee more information

Defined Benefit Beneficiary Change Request Form

Form #: 21

Product: Defined Benefit
Audience: Employee

17 Defined Benefit Employee Census Employer more information

Employee Census

Form #: 17

Product: Defined Benefit
Audience: Employer

DB-013b Defined Benefit, Defined Contribution, Hybrid Request for Projection Study Employer more information

Request for Projection Study

Form #: DB-013b

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer

DB-013A Defined Benefit Request for Benefit Change - Permanent or Temporary Employer more information

Request for Benefit Change - Permanent or Temporary

Form #: DB-013A

Product: Defined Benefit
Audience: Employer

10 Defined Benefit Transfer Of Contributions Within MERS Defined Benefit Plan (excluding Hybrid Benefit Program DB Component) Employee more information
5 Defined Benefit Defined Benefit Membership Application Employer, Employee False more information

Defined Benefit Membership Application

Form #: 5
Description:

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Product: Defined Benefit
Audience: Employer, Employee

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

DB-002c Defined benefit Addendum Defining Part-Time to Full-Time Service Credit Conversion Employer more information

Addendum Defining Part-Time to Full-Time Service Credit Conversion

Form #: DB-002c

Product: Defined benefit
Audience: Employer

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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).