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1111 East Main Street
Richmond, VA 23219
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1200 East Main Street
Richmond, VA 23219

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Forms

Forms
Form #DescriptionLast
Updated
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Hybrid Forms for Members opens web page
Hybrid Forms for Employers opens web page
N/A Minnesota Life/VRS Life Insurance Forms Page opens web page
N/A VRS Certificate of Life Insurance 07/2014 opens pdf 99kb
T-20879 State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants 12/2014 opens pdf 68kb
VSDP-2 College and University Opt-Out Form 09/2011 opens pdf 146kb
VRS-2 Designation of Beneficiary
To designate more than 3 beneficiaries, a continuation form, the VRS-2A, is also required.
01/2014 opens pdf 180kb
VRS-2A Designation of Beneficiary - Continuation 12/2014 opens pdf 148kb
VRS-3 Defined Benefit Plan Request for Refund
VRS now processes refunds online. Log in to myVRS to submit your refund request.
Please read the IRS 402(f) Special Tax Notice pdf icon before requesting your refund.
 
VRS-3A Name and Address Declaration For Deferred Members 02/2011 opens pdf 28kb
VRS-3ORP Request for Transfer of Funds to ORP 12/2015 opens pdf 261kb
VRS-5 Application for Retirement 01/2016 opens pdf 314kb
VRS-6 Application for Disability Retirement 10/2015 opens pdf 344kb
VRS-6A Explanation of Disability 12/2012 opens pdf 156kb
VRS-6B Physician's Report 08/2016 opens pdf 194kb
VRS-6C Request for Estimate of Disability Retirement Benefits 02/2011 opens pdf 33kb
VRS-6D Employer Information for Disability Application 02/2011 opens pdf 26kb
VRS-6E Certification of Alternate Employment for Disability Retiree for Political Subdivision Hazardous Duty Employees 08/2012 opens pdf 264kb
VRS-7ORP Notice of Return to Covered Employment Optional Retirement Plan Retiree 11/2012 opens pdf 217kb
VRS-8 Certification of Exception from General Early Retirement Provisions 07/2013 opens pdf 246kb
VRS-11 Employer Certification of Involuntary Separation Under the Workforce Transition Act 02/2016 opens pdf 389kb
VRS-11A Employer Certification of Basic Group Life Insurance Coverage Under Workforce Transition Act 02/2011 opens pdf 29kb
VRS-11B Employer Certification of Involuntary Separation Under the Transitional Benefits Program 02/2011 opens pdf 235kb
VRS-11C Employer Certification of VRS Basic Group Life Insurance Coverage Under the Transitional Benefits Program 02/2011 opens pdf 29kb
VRS-15 Request for Income Tax Withholding 02/2011 opens pdf 45kb
VRS-26 Application for Purchase of Prior Service Credit 05/2015 opens pdf 319kb
VRS-26C Authorization for After-Tax Payroll Deduction to Purchase Service Credit 03/2013 opens pdf 206kb
VRS-26E Agreement for Pre-Tax Salary Reduction to Purchase Service Credit 07/2016 opens pdf 215kb
VRS-27 Waiver of Life Insurance Coverage 02/2011 opens pdf 23kb
VRS-31 Accidental Dismemberment and Loss of Sight 12/2010 opens pdf 386kb
VRS-32 Group Life Evidence of Insurability 01/2011 opens pdf 344kb
VRS-35E Conversion of Group Life Insurance Enrollment 09/2013 opens pdf 712kb
VRS-37 Absolute Assignment of Group Life Insurance 02/2011 opens pdf 314kb
VRS-38 Assignees Change of Beneficiary 01/2011 opens pdf 352kb
VRS-39 Application for Optional Life Insurance 01/2011 opens pdf 325kb
VRS-39A Request for Change Under Optional Group Life Insurance Plan 02/2011 opens pdf 334kb
VRS-39R Retiree Optional Life Continuation 08/2013 opens pdf 299kb
VRS-45 Request for Health Insurance Credit
Retired participants who do not have premiums deducted from their VRS monthly benefit must complete this form.
09/2016 opens pdf 266kb
VRS-48 Request for Member Information Change 03/2013 opens pdf 219kb
VRS-49 Change to Certification for Retirement 02/2011 opens pdf 29kb
VRS-57 Authorization for Direct Deposit of Monthly Benefit 02/2011 opens pdf 31kb
VRS-58 Name and Address Declaration For Retirees 03/2013 opens pdf 252kb
VRS-61 Notification of Electronic Payment Information 12/2012 opens pdf 163kb
VRS-65 Election to Participate - Optional Retirement Plan for Higher Education 12/2014 opens pdf 229kb
VRS-65B Certification of Eligibility to Participate in Optional Retirement Plan for Political Appointees 02/2011 opens pdf 30kb
VRS-65D Termination Certification Form- Optional Retirement Plan for Higher Education 04/2013 opens pdf 238kb
VRS-65E Termination Certification Form - Optional Retirement Plan for Political Appointees 08/2014 opens pdf 164kb
VRS-65P Open Enrollment Provider Change - Optional Retirement Plan for Higher Education 09/2016 opens pdf 186kb
VRS-67A Authorization of Administrative Contacts 01/2013 opens pdf 54kb
VRS-70 Request for Review of Membership Records 02/2011 opens pdf 29kb
VRS-71B Termination Certification Form - Optional Retirement Plan for School Superintendents 08/2014 opens pdf 164kb
VRS-75 Optional Retirement Plan Health Insurance Credit Employer Certification of Service
Completed only by employers certifying Optional Retirement Plan participants.
12/2014 opens pdf 268kb
VRS-76 Certification of Employment for Health Insurance Credit Eligibility
Completed only by employers certifying general registrars, local officers, employees of these referenced positions and local social service employees.
12/2014 opens pdf 273kb
VRS-77 Certification of Hazardous Duty 02/2011 opens pdf 24kb
VRS-78 Authorization to Deduct Insurance Premiums and Application for Health Insurance Credit
Completed only by employers for non-state participants.
07/2013 opens pdf 151kb
VRS-83 Certification of Eligibility to Participate in Virginia Supplemental Retirement Plan 01/2009 opens pdf 99kb
VRS-160 Certification of Eligibility for Critical Shortage Teachers and Administrators 04/2010 opens pdf 254kb
VRS-160A Certification of Non-Participation of Critical Shortage Teachers and Administrators 04/2013 opens pdf 144kb
VRS-170 Authorization of Coverage Retention for the Long Term Care Plan (VSDP or VLDP) 01/2014 opens pdf 130kb
VRS-171 Protection Against Unintentional Lapse of Long Term Care (VSDP or VLDP) 01/2014 opens pdf 126kb
VRS-180 Employer Request for Forfeiture of Member Benefits 12/2015 opens pdf 88kb
VRS-900 Authorization to Discuss VRS Account Information 02/2011 opens pdf 33kb
VRS-901 VRS Durable Power of Attorney 07/2016 opens pdf 151kb
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