Retiree Info and Forms

These are the most commonly used and requested forms.
If you do not find what you need in this list, contact the Benefits Customer Service Team via email or at 703-228-3500, Option 1; 10 am to 4 pm.

• Application — Deferred Vested Retirement(PDF, 358KB)
• Policy on Retiree Health Insurance Changes(PDF, 190KB)
• Life Insurance Beneficiary Designation – The Hartford(PDF, 147KB)
• Direct Deposit Form for ACERS Pension
• Virginia State Tax Withholding form
  • Only complete if a resident of Virginia
• Federal State Tax Withholding form
  • The form does not provide space for withholding a set dollar amount or percentage. If you would like to do this, please indicate this at the top of the form

• ACERS Pension Refund or Rollover Packet(PDF, 384KB)

• Medicare Creditable Coverage Notice(PDF, 151KB)