HOME  /  Forms


Retirement or Refunds

If You Want to Retire

If you’re vested and want to collect your monthly benefit.

If You Want to Take a Refund

Take a refund or rollover of your contributions plus interest.

Other PERA Forms


General Forms      Benefit Recipients      Specialty Forms

Employer Forms


Employer Forms

Access Employer Forms


Back to top


General Forms

Change Form

Change your name, address, remove or add beneficiaries.

Release of information:

Use this form to release your personal information to another individual, agency, or firm. PERA will not release information without your consent.

Leave Verification

Use these forms to receive an estimate of the cost of purchasing service credit or maintaining your high-five salary for a leave of absence. Use this form for a non-military leave such as a personal, medical, or parental leave.

Leave Verification – Military

Use these forms to receive an estimate of the cost of purchasing service credit or maintaining your high-five salary for a leave of absence. Use this form for a military leave.


Back to top


Benefit Recipients

Direct deposit

Use this form for electronic deposit of your monthly benefit to your checking or savings account.

Your Pension and Taxes

A form to help you calculate your state and federal tax withholding

Tax Withholding Preference/Change Certificate

A form to change federal/state tax withholding from a PERA benefit.

Payment Recipient Address Change

If you are currently receiving a PERA benefit and need to change your address.



Back to top


Specialty Forms

Defined Contribution Plan

DCP Investment Selection

Employees should use this form to make alterations to how funds are invested in the Define Contribution Plan, or to transfer funds from previous investment choices into new ones.


Application for Defined Contribution Withdrawal (Active Employee)

Complete this form if you are employed by a Minnesota public employer and at least age 65. You may elect a distribution of all or a portion of your Defined Contribution Plan (DCP) account no more than once each calendar year.

Statewide Volunteer Firefighter (SVF)

Application for Lump Sum Retirement Benefit

Used by a firefighter who has severed his or her employment relationship with the fire department and wishes to receive a lump-sum benefit from the plan.

Application for Lump Sum Survivor Benefit

Used by the survivor of a firefighter who dies prior to receiving his or her retirement benefit.

Other Forms

Independent Contractor or Employee?

Complete this form to determine if you are an independent contractor or working in a PERA-covered position.

Benefit Options Worksheet

Which PERA pension is right for you? This worksheet may make the decision easier.





Back to top


Employee Eligibility or Exclusion

** Forms with an asterisk may only be used by employers who lack the ability to access PERA’s Employer Reporting and Information System (ERIS)

**Annual Exclusion Report

This form is only for use by employers who lack the internet and email capabilities to access PERA’s Employer Reporting & Information System (ERIS).  Complete this form to report employees who are excluded from PERA coverage.

Full-time Student Exclusion

Use this form to confirm exclusion from membership in PERA of any employee who is a full-time student and under the age of 23.

Notice of Non-Covered Employment or Provisional Coverage
Use this form to fulfill notification requirements for employees who are excluded because earnings are not expected to exceed the minimum threshold within the next 12 months. Employers are encouraged to use this form to provide written disclosure to all other excluded employees as well. In addition, this form should be used in situations when annual salary cannot be projected and provisional enrollment is taking place.

Eligibility Checklist 
Use this form to help determine PERA membership eligibility of your employees.

Individual Record of Earnings

Employers are to complete this form when responding to a request from PERA for the employment status and earnings of an individual whereby contributions were not reported to PERA from the beginning of employment with your agency; or reporting the earnings of a PERA-eligible employee who was either overlooked or mistakenly excluded and for whom deductions were not withheld.

Statement Concerning Your Employment in a Job Not Covered by Social Security (SSA-1945)

(Link will direct you to the Social Security Administration website)


Back to top


Enrollment Forms

** Forms with an asterisk may only be used by employers who lack the ability to access PERA’s Employer Reporting and Information System (ERIS)

Ambulance, Rescue or Volunteer Fire Fighter DCP Certification

Complete this form for an individual who meets the eligibility requirements of PERA’s Defined Contribution Plan (DCP) and has notified you of his or her desire to participate in the DCP.

City Manager/Administrator Election for General Plan After Opt-Out

City managers/administrators who had previously elected to not participate in PERA’s Coordinated Plan have the option to reverse that decision and become members of the Coordinated Plan by completing this form.

Elected Officials Membership

Use this form for elected public officials to determine which, if any, PERA plan to participate in.

Physician Membership Election 

Physicians working at a governmental institution must participate in the Coordinated plan, unless the physician opts, within 90 days, to participate in the Defined Contribution Plan. Use this form to make the selection.

City Manager Election for DCP or Opt-Out

City managers/administrators earning at least $5,100 per year must have salary deductions for the PERA Coordinated Plan unless the person elects instead to join the PERA Defined Contribution Plan, or chooses not to participate in any PERA retirement plan. Use this form to make a selection.

** Correctional Officer Certification

The purpose of this form is to certify the eligibility of an employee for the Local Correctional Employees Retirement Plan.

** Notice of Member Enrollment

Complete this form to enroll an employee whose coverage under the Coordinated, Correctional, Police and Fire or Basic plan is required. This form may only be used by employers who lack the ability to access PERA’s Employer Reporting and Information System (ERIS)


Back to top


Member Status

** Forms with an asterisk may only be used by employers who lack the ability to access PERA’s Employer Reporting and Information System (ERIS)

Discontinue DCP Participation – Elected Officials or City Managers

Minnesota law allows elected officials and city managers who are participating in the PERA Defined Contribution Plan (DCP) to discontinue membership at any point during their incumbency/employment. Upon doing so, however, the individuals may not receive a distribution of their DCP account balances until they terminate all public service. Use this form to elect to opt out of existing PERA coverage.

Leave Program Certification

Complete this form if you administer a leave/furlough program as a budgetary savings measure that could result in reduced salaries for PERA-covered employees of your unit.

** Member Information Change Report

Use this form to report changes that have occurred in the name or employment status of your PERA members.

PRO Conclusion – Verification of Employment Status 

Employers must advise PERA once an employee’s employment under a PRO agreement has concluded and/or when the employee terminates public service.

Labor Organization Employee Election

If you are a public employee who has been contributing to PERA’s Coordinated Plan and you are taking an authorized leave of absence from your employer to work for a labor organization that represents public employees, you may choose to continue to contribute to PERA from your earnings as a labor organization employee. Complete this form to continue contributions to PERA during your leave.

Leave Program Data File Template

Complete this spreadsheet to detail the effects of a leave/furlough program on PERA-covered employees’ salaries.

PRO – Phased Retirement Option Agreement

Complete this form to indicate an agreement between employer and PERA-covered employee to phase into retirement. This form should accompany a completed Application for PERA Retirement Benefits. As applicable, a signed copy of any subsequent Phased Retirement Agreement must also be provided to PERA prior to its effective date.


Back to top


Employer Status

Ambulance Service Questionnaire

This form is used to establish the eligibility of an ambulance service for inclusion in the PERA program.

Prospective Employer Questionnaire

Complete this form to determine eligibility of your organization to participate in PERA.

Exemption from Web Reporting

Payroll and personnel officers that have internet access and an email address at work are required to use PERA’s web-based Employer Reporting and Information System (ERIS) to report pay period contribution information and to enroll new members. Employers that lack the required computer technologies must complete this form to document that they are exempt from web reporting.

Verification of Employment Status – Privatization Plan

Complete this form to verify the employment status of a PERA member under a privatization plan.


Back to top


Tax and Contribution Reporting

Electronic Reporting Reconciliation Form

Employers must complete this form to alter a member’s transaction that has been reported in a current or past PERA computer file.

How to Report PERA Contributions on a W-2

This is a summary of basic guidelines for how to report Public Employees Retirement Association (PERA) pension contributions [all of PERA’s plans are IRS-qualified 401(a) pension plans] on IRS form W-2.




Back to top


Volunteer Firefighter Forms

Request for Cost Analysis

For a fire department that is considering joining the SVF to get an estimate of future annual contributions required to provide the level of benefits selected.

Request for Benefit Level Change

Used by a municipality or firefighting corporation in order to request a cost analysis of increasing the benefit level of a fire department that has already joined the plan.