Active Members

Beneficiary Designation

• Designation of Beneficiary
  KPERS-7/99, revised 4/11 (PDF, 274KB)
• Designation of Beneficiary for Life Insurance - Board of Regents
  KPERS-7/99A, revised 6/10 (PDF, 203KB)
• Additional Retirement Beneficiaries
  revised 6/10 (PDF, 178KB) - use this additional page if you have more retirement beneficiaries than space allows on the KPERS-7/99.
• Additional Life Insurance Beneficiaries
  revised 6/10 (PDF, 180KB) - use this additional page if you have more life insurance beneficiaries than space allows on the KPERS-7/99.

Elected Officials and Legislators

• Elected Official Irrevocable Election of Membership (non-legislative) KPERS-3, revised 2/10 (PDF, 186KB)
• KPERS Membership and Death and Disability Coverage (Legislators)
  KPERS-3A, revised 2/13 (PDF, 147KB)
• State Officer Retirement Plan Election
  KPERS-3S, revised 12/10 (PDF, 101KB)
• Election of Deferred Compensation Plan for KPERS Retirees (Legislators)
  KPERS-3R, revised 12-06 (PDF, 73KB)
• Election to Remain in the Board of Regents Retirement Plan During a Leave of Absence while Serving in the Kansas Legislature
  KPERS-4, revised 8/01 (PDF, 35KB)

Life Insurance

• Optional Group Life Insurance Reduction or Cancellation
  KPERS-79, revised 6/11 (PDF, 126KB)
• Optional Group Life Insurance Continuation
  KPERS-79C, revised 11/07 (PDF, 317KB)
• Minnesota Life Optional Group Life Insurance Enrollment Form
  revised 9/03 (PDF, 57KB)
• Minnesota Life Insurance Conversion Information and Form
  revised 9/08 (PDF, 123KB)
• Minnesota Life Election of Portable Term Life Coverage
  revised 9/08 (PDF, 96KB)
• Minnesota Life Insurance Accelerated Death Benefit Claim Form
  revised 12/10 (PDF, 33KB)

Personal Information

• Authorization to Release Information
  KPERS-14, revised 3/09 (PDF, 156KB)

Retirement

• Application for Retirement Benefits, Related Forms and Information
  KPERS-15 Booklet, revised 4/12 (PDF, 627KB) – Available in print
• Direct Deposit - Agreement for Payment of Benefit to Financial Institution
  KPERS-15B, revised 1/11 (PDF, 215KB)
• Retirement Benefit Estimate Request
  KPERS-15E, revised 4/13 (PDF, 143KB)
• Date of Birth Affidavit
  KPERS-40DOB, revised 6/11 (PDF, 134KB)
• Name Change Affidavit
  KPERS-40NC, revised 6/11 (PDF, 200KB)

Service Credit Purchase

• Application to Purchase Service Credit
  KPERS-67, revised 1/13 (PDF, 218KB)
• Application to Purchase Service Credit – Non-KPERS
  KPERS-67PS, revised 1/13 (PDF, 409KB)
• Application to Purchase Service Credit – Judges
  KPERS-67J, revised 11/07 (PDF, 398KB)
• Service Credit Purchase via Rollover
  KPERS-67R, revised 1/13 (PDF, 180KB)
• Service Credit Purchase With a Trustee-to-Trustee Transfer
  KPERS-67T, revised 1/13 (PDF, 61KB)

Withdrawal of Contributions

• Application for Withdrawal of Contributions, Related Forms and Information
  KPERS-13 Booklet, revised 9/12 (PDF, 279KB) – Available in print
• Important Tax Information Booklet
  revised 3/12 (PDF, 195KB) - contains important information about rollover
  and lump-sum payments.

Retired Members

Beneficiary Designation

• Designation of Beneficiary - Retired
  KPERS-7/99R, revised 10/10 (PDF, 235KB)
• Additional Retirement Beneficiaries
  revised 6/10 (PDF, 178KB) - use this additional page if you have more retirement beneficiaries than space allows on the KPERS-7/99R.

Benefit Payments

• Direct Deposit - Agreement for Payment of Benefit to Financial Institution
  KPERS-15B, revised 1/11 (PDF, 215KB)
• Withholding Certificate for Pension Benefit Payments (Substitute W-4P)
  revised 1/11 (PDF, 218KB) - simplified version of IRS W-4P
• Internal Revenue Service Withholding for Pension Payments
  IRS W-4P, (link to www.irs.gov)
  

Personal Information

• Change of Address Form for Retired and Inactive Members
  KPERS-700I, revised 10/01 (PDF, 33KB)
• Name Change Affidavit
  KPERS-40NC, revised 5/08 (PDF, 169KB)
• Authorization to Release Information
  KPERS-14, revised 1/13 (PDF, 175KB)

Working After Retirement

• KPERS Retiree Earnings Limitation Form
  KPERS-15S, revised 6/09 (PDF, 187KB)
• KP&F Retiree Earnings Limitation Form
  KP&F-15S, revised 6/10 (PDF, 142KB)

Disability Recipients

• Authorization for the Release of Information UHC form (PDF, 12KB)
• Authorization of Personal Representative UHC form (PDF, 13KB)
• Disability Payment Options UHC form (PDF, 15KB)
• Training - Education - Work Experience UHC form (PDF, 38KB)
• Employee's Withholding Allowance Certificate
  IRS W-4, (link to www.irs.gov)

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Beneficiaries

Beneficiary Designation

• Designation of Beneficiary - Retired
  KPERS-7/99R, revised 10/10 (PDF, 235KB)
• Additional Retirement Beneficiaries
  revised 6/10 (PDF, 178KB) - use this additional page if you have more retirement beneficiaries than space allows on the KPERS-7/99R.

Applying for Death Benefits

• Important Tax Information Booklet
  revised 10/10 (PDF, 164KB) - important information about rollovers
  and lump-sum payments

Employers

Death or Disability

• Employer's Report of Disability
  KPERS-60, revised 2/13 (PDF, 196KB)
• Employer's Report of Death
  KPERS-61, revised 6/11 (PDF, 211KB)

Designated Agent

• Designation of Agent
  KPERS-2, revised 12/11 (PDF, 299KB) - used to authorize individual staff members to conduct business with the Retirement System.
• Additional Employer Web Portal Access
  KPERS-2A, revised 11/12 (PDF, 160KB) - used to authorize employer web portal access. Designated agents and secondary signers automatically have full access.
• Change of Employer Contact Information
  KPERS-2B, revised 12/11 (PDF, 154KB) - used to update current employer, designated agent or secondary signer contact information.

Electronic Funds Transfer

• Authorization for Electronic Funds Transfer
  KPERS-EF105, revised 10/12 (PDF, 151KB)

Employment Information

• Report of Member Status
  KPERS-1, revised 4/09 (PDF, 258KB)
• Report of Employment for KPERS Retirees, Please report new retiree employment under "Enrollments" on the employer web portal.
• Retirement Plan Election for Kansas Board of Regents Employees
  KPERS-3BOR, revised 4/12 (PDF, 150KB)
• Employer Certification of Service
  KPERS-10, revised 7/99 (PDF, 45KB)
• Certification of Legislative Service (For Session Employees)
  KPERS-10LR, revised 1/99 (PDF, 24KB)
• Request for Member Information Change
  KPERS-12, revised 8/09 (PDF, 196KB)

Life Insurance

• Optional Group Life Insurance Return to Payroll
  KPERS-79R, revised 11/07 (PDF, 285KB)
• Minnesota Life Insurance Conversion Information and Form
  revised 9/08 (PDF, 123KB)
• Minnesota Life Election of Portable Term Life Coverage
  revised 9/08 (PDF, 96KB)
• Minnesota Life Insurance Accelerated Death Benefit Claim Form
  revised 5/03 (PDF, 33KB)

Publications

• Forms and Publications Order Form (PDF, 186KB)

Refunds and Arrearages

• Arrearage Adjustment to Prior Contribution Report – Employer Paid
  KPERS-17 EPD, revised 7/04 (PDF, 43KB)
• Arrearage/Refund Adjustment to Prior Contribution Report
  KPERS-17 OPT, revised 4/07 (PDF, 75KB)
• Arrearage Adjustment Factor Table
  KPERS-17 Table, revised 1/13 (PDF, 76KB)

Retirement

• Application for Retirement Benefits (Form Only)
  KPERS-15, revised 4/12 (PDF, 356KB)

Schools

• School Employee - Certification of Concurrent Employment
  KPERS-1C, revised 4/07 (PDF, 50KB)

Withdrawal of Contributions

• Application for Withdrawal of Contributions (Form Only)
  KPERS-13, revised 9/12 (PDF, 342KB)
• Supplemental Form - Withdrawal of Contributions
  KPERS-101, revised 5/00 (PDF, 36KB)

Kansas Police and Firemen's Retirement System (KP&F)

Death and Disability

• Application for Disability
  KP&F-523, revised 10/05 (PDF, 54KB)
• Physician's Report of Member's Condition
  KP&F-538, revised 8/01 (PDF, 48KB)
• KP&F Employer's Report of a Disability or On-The-Job Accident
  KP&F-560, revised 4/09 (PDF, 150KB)
• KP&F Employer's Report of Death
  KP&F-561, revised 10/11 (PDF, 91KB)

Working After Retirement

• KP&F Retiree Earnings Limitation Form
  KP&F-15S, revised 5/06 (PDF, 49KB)

Inactive Members

• Change of Address Form for Retired and Inactive Members
  KPERS-700I, revised 10/01 (PDF, 33KB)

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