Forms

Authorization for Release of Information
Complete this form to release your personal information to another individual or firm. DERP will not release information without your consent. This form must be signed and notarized.

Beneficiary Change
Log in to your MyDERP.org and click the Beneficiary link to view and update your beneficiaries.

Pre-Retirement Consent of Spouse
A member’s spouse must complete and sign this form when the member is designating a primary beneficiary that is not their spouse before retirement. This form must be signed and notarized.

Contribution Refund
Log in to your MyDERP.org account and click the Refund of Contributions link to request a refund or rollover of your contributions.

Retirement Application
The retirement process can be started in your MyDERP.org account but this form must be signed and notarized in order to confirm your choices.

Consent of Spouse
A retired member’s spouse must complete this form when a retired member elects the maximum benefit or a joint and survivor benefit for a beneficiary that is not their spouse. This form must be signed and notarized.

Common Law Affidavit
Complete this form to add your spouse to insurance coverage if you do not have a marriage certificate or your most recently filed tax return to confirm dependent verification. This form must be signed and notarized.

Address/Phone/Email Change
Log in to your MyDERP.org account and click the Account Info and/or the Address link to update your contact information.

Authorization for Release of Information
Complete this form to release your personal information to another individual or firm. DERP will not release information without your consent. This form must be signed and notarized.

Direct Deposit
Log in to your MyDERP.org account and click on the Direct Deposit link to make changes to your direct deposit information.

Direct Deposit Withdrawal Authorization
Complete this form to authorize DERP to withdraw funds from a designated account when there is a remaining balance for your insurance premium(s) after your monthly benefit and insurance subsidy are applied. This form must be signed and notarized.

Tax Withholding
Log in to your MyDERP.org account and click on the Tax Withholding link to make changes to your tax withholding elections.

Death Benefit Application
Complete this application if you are the beneficiary of a retired member who has passed away. This form must be signed and notarized.

Lump-Sum Death Benefit Application 
Complete this application if you are the beneficiary of a retired member who has passed away. This form must be signed and notarized.

Miscellaneous Death Benefit Application
Complete this application if you are the beneficiary of a member who has passed away and are eligible to receive benefits due to the member which were not paid before their passing. This form must be signed and notarized.

DROP Lump-Sum Distribution to a Beneficiary
Complete this form if you are the DROP beneficiary of a member who has passed away and are requesting to receive a distribution of the member’s DROP account. This form must be signed and notarized.

The DROP Program was offered to active DERP members from January 1, 2001, to August 31, 2023. The DROP Program is no longer offered.

DROP Distribution
If you’re in the DROP Program, log in to your MyDERP.org account and click the DROP Distribution link to request a distribution. Requests submitted before the 15th of the month are deposited in your account or mailed to the financial institution you designated on the second Friday of the following month.

DROP Paper Statement Request Form
Submit this form to request a paper copy of your DROP Statement. A $5 fee for each requested statement will be deducted from your DROP balance.

Health insurance elections can be completed in your MyDERP.org account during open enrollment. Changes to elections outside of open enrollment must be completed using a paper form and only if the member has experienced a life event.

If have experienced a qualifying life event, your forms must be submitted within 30 days of a qualifying life event along with proof of the qualifying life event.

Health Insurance Election Form
Complete this form if you are a new retiree and want to enroll in health insurance, or if you’ve experienced a qualifying life event and need to modify your current elections. This form must be signed.

Health Insurance Disenrollment Form
Use this form to cancel your health insurance coverage. Cancellations are effective the first of the month following receipt. This form must be signed by the member.

Direct Deposit Withdrawal Authorization
Complete this form to authorize DERP to withdraw funds from a designated account when there is a remaining balance for your insurance premium(s) after your monthly benefit and insurance subsidy are applied. This form must be signed and notarized.

Domestic Relations Order Agreement
This form sets the terms of the domestic relations order and must be signed by the member, the former spouse, and be notarized. If the member and/or former spouse are represented by legal counsel, the attorney(s) must also sign the form.

Domestic Relations Order Court Form
This form must be completed and signed by the District Court Judge/Magistrate and submitted with the Domestic Relations Order Agreement.

Domestic Relations Order Release Authorization
Complete this form to authorize DERP to release information to the parties involved in the domestic relations order. This form must be signed and notarized.

Domestic Relations Order Parties
Use this form to verify the parties involved in the domestic relations order. This form must be signed by the member.

Domestic Relations Order Benefit Application
This application is competed by the member’s former spouse in the approved domestic relations order to receive their portion of the benefit upon the member’s retirement. The form must be signed and notarized.

Service Credit Purchase Application
Complete this form to purchase service with DERP. This form must be signed.

Service Credit Purchase Direct Transfer Certification
Complete this form to purchase service with funds from a qualified retirement account. A portion of this must be completed by the custodian of the fund. This form must be signed.

Service Credit Purchase Non-Governmental Affidavit
Complete this affidavit to affirm your eligibility and intent to purchase non-governmental service. This form must be signed.

Service Credit Purchase Prior-Governmental Employment Verification 
Use this form to verify your prior-governmental service and eligibility to purchase prior-governmental service. This form must be signed.