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Counseling Center
1111 East Main Street
Richmond, VA 23219
8:30 a.m.–4:00 p.m.
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Administrative Offices
1200 East Main Street
Richmond, VA 23219

 > Forms


member Forms
Form #DescriptionLast
Hybrid Forms for Members 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
You MUST read the IRS 402(f) Special Tax Notice pdf icon before filling out this form.
01/2016 opens pdf 287kb
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 02/2011 opens pdf 93kb
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-7ORP Notice of Return to Covered Employment Optional Retirement Plan Retiree 11/2012 opens pdf 217kb
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.
11/2013 opens pdf 191kb
VRS-48 Request for Member Information Change 03/2013 opens pdf 219kb
VRS-57 Authorization for Direct Deposit of Monthly Benefit 02/2011 opens pdf 31kb
VRS-65 Election to Participate - Optional Retirement Plan for Higher Education 12/2014 opens pdf 229kb
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-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-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-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-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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