All Forms By Form Number

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All forms for members are listed here, but not all are available through this website. In some cases, you may need to see your employer for the form or for a sample of it. In certain cases, the Retirement Systems Division only provides the forms upon request.

Form 11S

Monthly Remittance of Fees for the Register of Deeds' Supplemental Pension Fund

Form 170

Authorizing Direct Deposit

Form 170S

Survivor's Benefit: Authorizing Direct Deposit

Form 237

Reporting Your 2008 Income To Continue Your Retirement System Disability Benefit

Form 276

Designating Beneficiary(ies) for the Separate Insurance Benefit Plan for Law Enforcement

Form 290

Choosing Income Tax Withholding Preferences

Form 290S 

Survivor's Benefit: Choosing Income Tax Withholding Preferences

Form 296 

Reporting Your 2008 Income To Continue Your Benefit Through the Disability Income Plan

Form 297

Reporting Your 2008 Income to Continue Your Disability Salary Continuation Plan Benefit

Form 2C

Designating Beneficiary(ies) for Retirement System Contributions and the Death Benefit

Form 309

Estimating Your Service Retirement Benefits

Form 319

Choosing to Transfer Supplemental Income Plan Contributions for an Additional Monthly Benefit (LEOs only)

Sample Form 333

Choosing the Contributory Death Benefit for Retired Members

Sample Certificate

Certificate of Coverage (duplicates available upon request)

Form 336

Designating Beneficiary(ies) for the Guaranteed Refund as a Retiree

Form 348

Requesting Leave of Absence in the Firemen's and Rescue Squad Workers' Pension Fund

Form 349

Purchasing Pension Fund Credit for Prior Fire or Rescue Service

Form 350

Enrolling in the Firemen's and Rescue Squad Workers' Pension Fund

Form 359

Transferring Accounts in the Firemen's and Rescue Squad Workers' Pension Fund

Form 398

Using A Distribution of Tax-Sheltered Savings to Purchase Retirement Credit

Form 430

Purchasing Retirement Credit for a Period of Interrupted Service Related to Parental Leave

Form 432

Purchasing Retirement Credit for a Period of Interrupted Service Due to Involuntary Furlough

Form 441

Purchasing Retirement Credit for a Period of Workers’ Compensation

Form 443

Purchasing Retirement Credit for State or Local Government Temporary Employment

Form 451

Purchasing Retirement Credit for a Period of Part-Time State or Local Government Employment

Form 452

Purchasing Retirement Credit for a Period of Service with a Non-Participating Local Unit

Form 455

Purchasing Retirement Credit for a Period of Out-of-State Employment

Form 461

Purchasing Retirement Credit for Withdrawn Service

Form 462

Purchasing Retirement System Credit or Requesting Free Credit for Military Service

Form 463

Purchasing Retirement Credit for a Period of Interrupted Service for Educational Purposes

Form 463F

Requesting Continuation of Contributions and Credit for Planned Educational Leave

Form 466

Purchasing Retirement Credit for Unreported Service Omitted Through Error

Form 467

Purchasing Retirement Credit for a Period of Federal Service

Form 470

Purchasing Retirement Credit for a Waiting Period Imposed by a Local Unit

Form 478

Purchasing Retirement Credit for Withdrawn Optional Retirement Program Service

Form 479

Purchasing Retirement Credit for a Period of Federally-Funded Service

Form 481

Purchasing Retirement Credit for a Period of Service Not Credited by the Former LEORS

Form 485

Purchasing Retirement Credit for a Period of Interrupted Service Due to Extended Illness

Form 499

Purchasing Retirement Credit for a Period of Service with a Non-Participating Charter School

Form 5

Withdrawing Your Retirement Service Credit and Contributions

Form 5FR

Withdrawing Contributions from the Firemen's and Rescue Squad Workers' Pension Fund

Sample Form 5ROC

Choosing the Return of Contributions

Sample Form 5TR

Transferring Service and Contributions Between Systems

Form 6

Claiming Your Monthly Retirement Benefit (all Systems)

Form 6C

Reporting an Employee's Work Record for Retirement

Sample Form 6E

Choosing Your Retirement Payment Option

Sample Form 6EJ

Choosing Your Retirement Payment Option for the Consolidated Judicial Retirement System

Sample Form 6EL

Choosing Your Retirement Payment Option for the Legislative Retirement System

Sample Form 6ER

Authorizing Your New Spouse As Beneficiary

Form 6FR

Retiring from the Firemen's and Rescue Squad Workers' Pension Fund

Sample Form 6SAB

Choosing the Survivor's Alternate Benefit

Form 7

Requesting Disability Retirement Benefits

Sample Form 700 Requesting Employer Informaiton Required for Member Disability Income Plan Benefits
Form 701

Requesting Short-Term of Benefits Through the Disability Income Plan of North Carolina

Form 703

Medical Report for Eligibility Review of Short-Term Disability Benefits

Form 704

Requesting Additional Benefits Through the Disability Income Plan of North Carolina

Sample Form 705

Agreeing to Accept Long-Term Benefits through the Disability Income Plan of N.C.

Form 706

Confirming an Employee's Resignation for Disability

Form 707

Reporting Earnings Monthly While Receiving Extended Short-Term or Long-Term Benefits

Sample Form 708

Making the Decision Between Disability Income Plan or Disability Retirement Benefits

Form 709

Estimating Your Disability Retirement Benefits

Form 710

Determining the Waiting Period Before the Short Term Begins

Sample Form 711 Determining and Recording Short-Term Disability Benefits
Sample Form 714

Requesting Reimbursement and Service Credit for the Short-Term Period

Form 7A

Medical Report for Disability Eligibility Review

Form 7AR

Medical Report for Disability Re-examination

Sample Form 7E

Choosing a Disability Retirement Payment Option

Form 7FR

Requesting Disability Status from the Firemen's and Rescue Squad Workers' Pension Fund

Form COA

Updating Your Addresses or Name (not for currently contributing members)

Form DB228

Choosing Tax Treatment for a Payment of Undistributed Contributions Due to a Death

Form HM

Selecting Health Coverage Through the State Health Plan

Form MR

Authorizing the Release of Medical Records

Form SVC

Reviewing Your Service Record and Requesting an Audit of Your Service Credit