Forms Listed by Number

• KPERS-1, Report of Member Status, Revised 4/09 (PDF, 258KB)
• KPERS-1R, Please report new retiree employment under "Enrollments" on the employer web portal.
• KPERS-1C, School Employee - Certification of Concurrent Employment, Revised 4/06 (PDF, 50KB)
• KPERS-2, Designation of Agent, Revised 12/11 (PDF, 299KB)
• KPERS-2A, Additional Employer Web Portal Access,
  Revised 12/11 (PDF, 160KB)
• KPERS-2B, Change of Employer Contact Information,
  Revised 12/11 (PDF, 154KB)
• KPERS-3, Elected Official Irrevocable Election of Membership (non-legislative), Revised 2/10 (PDF, 186KB)
• KPERS-3A, KPERS Membership and Death and Disability Coverage (for Legislators), Revised 12/10 (PDF, 162KB)
• KPERS-3R, Election of Deferred Compensation Plan for KPERS Retirees (Legislators) KPERS-3R, revised 12-06 (PDF, 73KB)
• KPERS-3S, State Officer Retirement Plan Election, Revised 12/10
  (PDF, 101KB)
• KPERS-3TK, Election of Continuation of KPERS Membership or TIAA-CREF Assistance, Revised 3/01 (PDF, 46KB)
• KPERS-4, Election to Remain in the Board of Regents Retirement Plan During a Leave of Absence while Serving in the Kansas Legislature, Revised 8/01 (PDF, 35KB)
• Substitute W-4P, Withholding Certificate for Pension Benefit Payments
  revised 1/11 (PDF, 218KB) - simplified version of IRS W-4P
• IRS W-4P, Internal Revenue Service Withholding for Pension Payments form (PDF, 277KB)
• IRS W-4, (For Disability Recipients) Employee's Withholding Allowance Certificate (link to www.irs.gov)
  
• KPERS-7/99, Designation of Beneficiary, revised 4/11 (PDF, 274KB)
• KPERS-7/99R, Designation of Beneficiary - Retired, Revised 10/10
  (PDF, 235KB)
• KPERS-7/99A, Designation of Beneficiary for Life Insurance - Board of Regents , 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.
• KPERS-10, Employer Certification of Service, Revised 7/99 (PDF, 45KB)
• KPERS-10LR, Certification of Legislative Service (For Session Employees), Revised 1/99 (PDF, 24KB)
• KPERS-12, Request for Member Information Change, Revised 8/09
  (PDF, 196KB)
• KPERS-13 Booklet, Application for Withdrawal of Contributions and Related Forms, Revised 6/11 (PDF, 400KB) – Available in print
• KPERS-13, Withdrawal of Contributions, (Form Only) Revised 6/11
  (PDF, 279KB)
• KPERS-14, Authorization to Release Information, Revised 3/09
  (PDF, 156KB)
• KPERS-15 Booklet, Application for Retirement Benefits and Related Forms,
  Revised 5/11 (PDF, 635KB) – Available in print
• KPERS-15, Application for Retirement Benefit, (Form Only) Revised 5/11 (PDF, 390KB)
• KPERS-15B, Direct Deposit - Agreement for Payment of Benefit to Financial Institution, Revised 1/11 (PDF, 215KB)
• KPERS-15E, Retirement Benefit Estimate Request, Revised 2/06
  (PDF, 35KB)
• KPERS-15S, KPERS Retiree Earnings Limitation Form, Revised 6/09
  (PDF, 187KB)
• KP&F-15S, KP&F Retiree Earnings Limitation Form, Revised 6/10
  (PDF, 142KB)
• KPERS-17 EPD, Arrearage Adjustment to Prior Contribution Report -- Employer Paid, Revised 7/04 (PDF, 43KB)
• KPERS-17 OPT, Arrearage/Refund Adjustment to Prior Contribution Report, Revised 4/07 (PDF, 75KB)
• KPERS-17 Table, Arrearage Adjustment Factor Table, Revised 12/11
  (PDF, 100KB), Word doc
• Important Tax Information Booklet, Revised 10/10 (PDF, 164KB)
• KPERS-40DOB, Date of Birth Affidavit, Revised 6/11 (PDF, 134KB)
• KPERS-40NC, Name Change Affidavit, Revised 6/11 (PDF, 200KB)
• KPERS-60, Employer's Report of Disability, Revised 5/10
  (PDF, 192KB)
• KPERS-61, Employer's Report of Death, Revised 6/11
  (PDF, 211KB)
• KPERS-67, Application to Purchase Service Credit , Revised 4/11
  (PDF, 259KB)
• KPERS-67J, Application to Purchase Service Credit – Judges, Revised 11/07 (PDF, 398KB)
• KPERS-67PS, Application to Purchase Service Credit – Non-KPERS, Revised 5/08 (PDF, 409KB)
• KPERS-67R, Service Credit Purchase via Rollover, Revised 7/07
  (PDF, 180KB)
• KPERS-67T, Service Credit Purchase With a Trustee-to-Trustee Transfer and Fact Sheet, Revised 3/07 (PDF, 61KB)
• KPERS-78, Affiliation for Optional Group Life Insurance, Revised 5/08
  (PDF, 217KB)
• KPERS-79, Optional Group Life Insurance Reduction or Cancellation, Revised 6/11 (PDF, 126KB)
• KPERS-79C, Optional Group Life Insurance Continuation, Revised 11/07 (PDF, 317KB)
• KPERS-79R, Optional Group Life Insurance Return to Payroll, Revised 11/07 (PDF, 284KB)
• KPERS-101, Supplemental Form - Withdrawal of Contributions, Revised 5/00 (PDF, 36KB)
• KPERS-EF105, Authorization for Electronic Funds Transfer, Revised 12/07 (PDF, 125KB)
• KP&F-523, Application for Disability, Revised 10/05 (PDF, 54KB)
• KP&F-538, Physician's Report of Member's Condition, Revised 8/01
  (PDF, 48KB)
• KP&F-560, Employer's Report of a Disability or On-The-Job Accident
  Rrevised 4/09 (PDF, 150KB)
• KP&F-561, Employer's Report of Death, Revised 10/11 (PDF, 91KB)
• KPERS-700I, Change of Address Form for Retired and Inactive Members,
  Revised 10/01 (PDF, 33KB)
• 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)
• Forms and Publications Order Form, Revised 2/06 (PDF, 25KB)