Miscellaneous Forms
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Form 101 Nomination of Beneficiary
This form is to be used to nominate the person or persons to receive any death benefit payable by the State Employees' Retirement System of Illinois. This is a legal document which, after preparation, may not be altered in any way by any person. A member desiring to change beneficiaries at a later date must complete a new Beneficiary form. The form on file with SERS that has the most recent date, located next to the member's signature, will take precedence. http://www.state.il.us/srs/PDFiles/Forms/101.pdf
Form 501 Change of Address
This form may be used by benefit recipients only to make an address change. If you are an active employee, you must contact your payroll office to make an address change. http://www.state.il.us/srs/PDFiles/Forms/501.pdf
Form 521 Workshop Reservation
This form is used by members to register for the educational preretirement workshops. These workshops give you first hand information about important topics relating to your retirement and current assessments. http://www.state.il.us/srs/PDFiles/Forms/521.pdf
Form 2003 Service Credit Request
This form is used by members to request estimates on the purchase of optional service.
http://www.state.il.us/srs/PDFiles/Forms/2003.pdf
Form 3034 Request for Payment to Trust
The appropriate legal documents establishing the trust must accompany this form. A trust is a property arrangement on which a trustee, such as a person or a bank trust department, holds title to, takes care of , and in most cases, manages property for the benefit of one or more third parties (beneficiaries). You should seek legal advice if you are setting up a trust. http://www.state.il.us/srs/PDFiles/Forms/3034.pdf
Form 3606 Small Estates Affidavit
This document is used when the total of an Illinois decedent's estate is less than $100,000.00 AND the estate does not own real estate. A small estates affidavit may be used to transfer property to the decedent's beneficiaries/heirs without opening a formal probate estate. You should seek legal advice to complete this form. http://www.state.il.us/srs/PDFiles/Forms/3606.pdf
Form 3967 SERS Direct Deposit Request
This form is used to set up or change the direct deposit of SERS benefit payments. Your signature must be on the form before SERS can take any action. Your bank must complete and sign part III. http://www.state.il.us/srs/PDFiles/Forms/3967.pdf
W-4p Federal Withholding Certificate
This form is used to change Federal tax withholding from your SERS payment. http:www.state.il.us/srs/PDFiles/fw4p.pdf
SERS State Income Tax Withholding Certificate
This form is used to withhold state income tax from your SERS payment. While you are not required to pay state income tax on your SERS benefit, you may wish to have a tax deduction under some circumstances. If so, complete this form and send to SERS Vouchering Section http://www.state.il.us/srs/PDFiles/Forms/SERS_State.pdf
Pension Benefit Forms
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Retirement Packet and other Retirement Information
This packet is used for starting your retirement process in a step by step instruction. There are other helpful tools within this area to help with your retirement questions. http://www.state.il.us/srs/sers/Ret_Information.htm
Form 3017 Waiver of Disability Benefits
This form is used to discontinue receiving disability benefits and begin receiving a pension benefit. http://www.state.il.us/srs/PDFiles/Forms/3017.pdf
Form 3035 Waiver of Widow/Survivor Contribution Refund
This form is used if you have no qualifying survivor (i.e. spouse, child, parent) when you begin your pension benefit. You are eligible to receive a refund of your widow's/survivor's contributions. http://www.state.il.us/srs/PDFiles/Forms/3035.pdf
Form 3152 Alternative Formula Contribution Refund
This form is used if you participated under an alternative formula, but do not qualify for an alternative formula pension. You are eligible for a refund of the excess contributions paid. This form is automatically sent with information provided by the SERS Pension Section. If you misplaced the original sent to you, download this form. Please see the Tax Information brochure located in the SERS publications section of this web site. http://www.state.il.us/srs/PDFiles/Forms/3152.pdf
Form 3844 Reversionary Annuity
This form is to be completed if you are electing a reversionary annuity. A reversionary annuity is paid when you voluntarily reduce your monthly retirement annuity to provide a portion of that annuity to your surviving spouse upon your death. Please read the Reversionary Annuity booklet provided to you in the publications section of the SERS web site. If you are interested, call SERS Pension Section and they will provide you with information needed to complete this form. http://www.state.il.us/srs/PDFiles/Forms/3844.pdf
Form 3967 Depository Agreement for SERS Benefit Payments
This form is used to set up or change the direct deposit of SERS benefit payments. Your signature must be on the form before SERS can take any action. Your bank must complete and sign part III. http://www.state.il.us/srs/PDFiles/Forms/3967.pdf
Widow/Survivor Benefit Forms
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Form 3033 Student Recertification/Decertification for Survivor's Annuity
This form is automatically sent to the appropriate survivor's benefit recipients. If you misplaced the original sent to you this form can be downloaded and used. Please have the school you attend complete the lower portion of the form. http://www.state.il.us/srs/PDFiles/Forms/3033.pdf
Form 3967 Depository Agreement for SERS Benefit Payments
This form is used to set up or change direct deposit of SERS benefit payments. Your signature must be on the form before SERS can take any action. Your bank must complete and sign part III. http://www.state.il.us/srs/PDFiles/Forms/3967.pdf
Insurance Forms
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Form 3841 Deferred Annuitant Insurance Enrollment Form
This form is used for insurance enrollment for members who retire one year or more after terminating state service. Insurance enrollment will not be activated until all pension paperwork and required documentation is received. http://www.state.il.us/srs/PDFiles/Forms/3841.pdf
Form 3841-1 Immediate Annuitant Enrollment Form
This form is used for insurance enrollment for members within one year of terminating state employment and have not been enrolled in the State of Illinois group insurance program within the last 30 days before terminating state employment. Insurance enrollment will not be activated until all pension paperwork and required documentation is received. http://www.state.il.us/srs/PDFiles/Forms/3841_i.pdf
Disability Benefit Forms
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All 3 Disability Packets
All three Disability Packets (Non-Occupational, Occupational, and Temporary) are availible. These packets are used for starting your disability process in a step by step instructional packet. http://www.state.il.us/srs/sers/Dis_general_sers.htm
Form 3114 Non-Occupational Disability Medical Report
This form is used as part of the non-occupational disability application packet. This form must be completed by a licensed medical doctor. http://www.state.il.us/srs/PDFiles/Forms/3114.pdf
Form 3128 Certification of Disability
This form is sent to all disability recipients semi-annually. If you misplaced the certification sent by SERS you can download it for completion and send to the SERS disability section. http://www.state.il.us/srs/PDFiles/Forms/3128.pdf
Form 3129 Unreduced Social Security Pension Benefits
If you are receiving a Non-Occupational or Temporary disability benefit, this form is used when you become eligible for the unreduced pension from the SSA. The information will be used to reduce your SERS disability benefit. This form will be sent to you prior to your eligibility for the unreduced SSA pension. http://www.state.il.us/srs/PDFiles/Forms/3129.pdf
Form 3135 Temporary Disability Medical Report
This form is used as part of the Temporary Disability application packet. It must be completed by a licensed medical doctor. To apply for this benefit, you must be denied benefits under the Workers' Compensation Act or have your Workers' Compensation benefits terminated and you have appealed this termination. http://www.state.il.us/srs/PDFiles/Forms/3135.pdf
Form 3213 Occupational Disability Medical Report
This form is used as part of the Occupational Disability application packet. It must be completed by a licensed medical doctor. If you have applied or are receiving Total Temporary disability benefits from the Dept. of Risk Management or received a settlement/award regarding a work-related disability, you can apply for Occupational Disability benefits. http://www.state.il.us/srs/PDFiles/Forms/3213.pdf
Form 3934 Release of Information Authorization
This form is used with the disability investigation process. The completion of this form is needed to provide a current authorization for release of records. SERS will send you this form when needed. If you misplaced the original form sent by SERS, you can download it. http://www.state.il.us/srs/PDFiles/Forms/3934.pdf
Form 3967 Depository Agreement for SERS Benefit Payments
This form is used to set up or change the direct deposit of SERS benefit payments. Your signature must be on the form before SERS can take any action. Your bank must complete and sign part III. http://www.state.il.us/srs/PDFiles/Forms/3967.pdf
