Forms/Kits/Handbooks

PERA offers publications about its benefits and services that can be an invaluable resource. All publications and forms are available to download or print in PDF format.

  • Forms
    • Adjusted Qualification Record

      To be used by an individual Firefighter to adjust/correct service credit for prior years which their department reported incorrectly or failed to report. This form must be submitted with the "Adjusted Qualification Report".

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      Adjusted Qualification Report

      This form is to be signed by the member in front of a notary public certifying the information on the "Adjusted Qualification Record" is true and correct. This form must also be signed by the mayor or chair of the county commission.

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      Affidavit for Free Military Service

      To be used by a members called to active military service while actively employed by a PERA affiliated-employer to certify the dates of employment and military service.

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      Application for Disability Retirement Benefits

      Application for Disability Retirement Benefits

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      Application for Volunteer Firefighter Pension

      Application for Volunteer Firefighter Pension

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      Application for Annuity

      To be used to apply for Annuity.

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      Application for Pension

      To be filled out when applying for pension.

      Download Form

      Attorney's Instructions & Model Dividing PERA Benefits

      Attorney instructions for Orders Dividing PERA Retirement Benefits

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      Attorney's Instructions Order Changing Form of Payment

      Attorney's Instructions Order Changing Retirement Benefits Form of Payment

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      Authorization to Release Information

      To be used to give authorization to release information.

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      Beneficiary Designation

      To be used by an active member to designate a survivor and refund beneficiary to receive a death benefit after the death of the member. This is a new form that combines both beneficiary designations.

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      Beneficiary Spousal Consent Form

      To be used for a spouse to consent if member is selecting a beneficiary other than the spouse.

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      Change in PERA Records

      To be used by all active members to notify PERA of a change of address, a change of name or a change of social security number.

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      Change in Retirement Date

      To be used to change a member's retirement date after the member has submitted a completed retirement kit to PERA.

      Download Form

      Co-payee Refund Form

      To be used by co-payee.

      Download Form

      Examining Physician's Statement for Disability Benefits

      Examining Physician's Statement for Disability Benefits

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      Member Enrollment for State Legislator Member Coverage Plan 2

      Enrollment form for state legislator members.

      Download Form

      PERA Request Form

      To be used by an active member who wishes to request an estimate of benefits (must be within 3 years of retirement); cost calculations for air time, with drawn service, or military service; prepare a service credit verification or request a PERA Retirement Kit.

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      Re-evaluation Application for Disability Retirement Benefits

      Reevaluation Application for Disability Retirement Benefits

      Download Form

      Volunteer Firefighter Annual Reporting

      To be used by the department for online reporting.

      Download Form

      Volunteer Firefighter Contact Form

      To be used to provide contact information for the online reporting.

      Download Form

      Volunteer Firefighter Enrollment Form

      To be used by people enrolling in the volunteer firefighter program.

      Download Form

      Volunteer Firefighter Service Credit Qualification Record

      To be used by the department chief to report service credit for the entire department. This form must be received by PERA by March 31 of each year to ensure credit is given for the individuals in the department.

      Download Form
  • Kits
    • PERA Retirement Kit

      Instructions detailing the Retirement Process

      Download Kit

      PERA Retirement Kit Forms

      Forms required for the Retirement Process

      Download Kit

      PERA Disability Retirement Kit

      Instructions detailing the Disability Retirement Process

      Download Kit

      PERA Disability Retirement Kit Forms

      Forms required for the Disability Retirement Process

      Download Kit
  • Handbooks