Forms

Overview

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Form DocuSign E-Form PDF
ACERA Welcome Form   PDF
Active or Deferred Member Beneficiary Addendum       PDF
Active or Deferred Member Beneficiary Designation Form  

PDF

Video

Address and Name Change Form (Retirees, Payees, and Deferred Members) DocuSign PDF

Advance Death Benefit Election

(on Active or Deferred Member Beneficiary Designation Form)

 

PDF

Video

Affidavit of Dependent Eligibility DocuSign PDF
Affidavit of Domestic Partnership   PDF
Agreement and Order for Division of Retirement Benefits – Separate Records   PDF
Agreement and Order for Division of Retirement Benefits – Shared Records   PDF
Application For Disability Retirement (Sample Only)   PDF
Application for Service Retirement DocuSign  
Aquilino Tier 1 Restoration Application   PDF
Authorization for Release of Information and Documents   PDF
Community Property Estimate Request Form   PDF
Continuance Beneficiary Addendum DocuSign  
Declaration of Qualification for Registration as Domestic Partners   PDF
Dental Plan Enrollment Form DocuSign PDF
Direct Deposit Form   PDF
Disability Website  
HIPAA Authorization Form   PDF
HIPAA Cancellation Form   PDF
IRS Form W-9 DocuSign PDF
Kaiser Permanente Senior Advantage (KPSA) Enrollment Form DocuSign PDF
Lump-Sum Death Benefit Beneficiary Addendum DocuSign  
Medical Plan Enrollment Form DocuSign PDF
Medicare Part B Reimbursement Plan (MBRP) Application Form DocuSign PDF
Non-Member Application for Retirement Allowance   PDF
Non-Member Beneficiary Form   PDF
Notice of Claim   PDF
Other Public Service Verification Form   PDF
Power of Attorney   PDF
Purchase Request Form DocuSign PDF
Purchase Request Form FAQ   PDF
REAC Enrollment Form DocuSign  
Report a Death Form Web Form  
Request for Joinder Packet   PDF
Retired Member Beneficiary Designation Form   PDF
Retiree Association – ACRE Enrollment Form DocuSign PDF
Retiree Associations – ACRE and REAC Membership Termination Form DocuSign PDF
Retirement Estimate Request Form DocuSign PDF
Retirement Payment Option Addendum DocuSign PDF
Service-Connected Death Allowance Application DocuSign PDF
SSA-44 Form (Medicare Income-Related Monthly Adjustment Form)   PDF
Survivor Continuance Recipient’s Designation of Beneficiaries Form   PDF
Tax Withholding Designation Form (IRS Federal Form W-4P) DocuSign PDF
Tax Withholding Designation Form (State of California) DocuSign PDF
Termination Election Form   PDF
Termination of Domestic Partnership   PDF
Verification of Enrollment Status   PDF
Via Benefits Reimbursement Forms Website  
Vision Plan Enrollment Form DocuSign PDF
VSP Reimbursement Forms: Login at VSP website Website