for Members and Retirees
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All forms are fillable and ready for download and printing. VRS accepts all forms by mail or fax. Fax to: 804-786-9718. If on deadline when faxing a form, please call or email to alert VRS of its pending arrival. VRS does not accept forms via email, which is not a secure form of communication.
Note: VRS does not accept forms via email, which is not a secure form of communication.
| Form # | Title/Description | Last Updated | Download/Link |
|---|---|---|---|
| N/A | Approved Domestic Relations Orders - Defined Benefit Plan | 08-2019 | |
| N/A | Approved Domestic Relations Orders - Defined Contribution Account(s) | 08-2019 | |
| ALL | All Hybrid Retirement Plan Forms | N/A | |
| ALL |
Securian Financial/VRS Life Insurance Forms
VRS-31, VRS-32, VRS-35, VRS-37, VRS-38, VRS-39, VRS-39A, VRS-39R and VRS Certificate of Life Insurance. |
N/A | |
| IRS 402(F) |
IRS 402(f) - Special Tax Notice - VRS Defined Benefit Plans
Before taking a refund, read this notice, which explains the tax consequences of taking a refund versus direct rollover into another plan. |
10-2020 | |
| T-20879 | State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants | 03-2020 | |
| VSDP-2 | College and University Opt-Out Form | 09-2011 | |
| VRS-2 |
Designation of Beneficiary
To designate more than 3 beneficiaries, a continuation form, the VRS-2A, is also required. |
02-2020 | |
| VRS-2A | Designation of Beneficiary - Continuation | 02-2020 | |
| VRS-3A | Name and Address Declaration For Deferred Members | 02-2011 | |
| VRS-3ORP | Request for Transfer of Funds to ORP | 07-2019 | |
| VRS-5 | Application for Service Retirement | 08-2020 | |
| VRS-6 | Application for Disability Retirement | 05-2020 | |
| VRS-6A | Explanation of Disability | 01-2019 | |
| VRS-6B | Physician's Report | 01-2019 | |
| VRS-6C | Request for Estimate of Disability Retirement Benefits | 02-2011 | |
| VRS-6D | Employer Information for Disability Application | 10-2020 | |
| VRS-6E | Certification of Alternate Employment for Disability Retiree for Political Subdivision Hazardous Duty Employees | 08-2012 | |
| VRS-7ORP | Notice of Return to Covered Employment Optional Retirement Plan Retiree | 11-2012 | |
| VRS-8 | Certification of Exception from General Early Retirement Provisions | 07-2013 | |
| VRS-11 | Employer Certification of Involuntary Separation Under the Workforce Transition Act | 02-2016 | |
| VRS-11A | Employer Certification of Basic Group Life Insurance Coverage Under Workforce Transition Act | 02-2011 | |
| VRS-11B | Employer Certification of Involuntary Separation Under the Transitional Benefits Program | 06-2015 | |
| VRS-11C | Employer Certification of VRS Basic Group Life Insurance Coverage Under the Transitional Benefits Program | 02-2011 | |
| VRS-15 | Request for Income Tax Withholding | 08-2020 | |
| VRS-26 | Application for Purchase of Prior Service Credit | 08-2017 | |
| VRS-26C |
Authorization for After-Tax Payroll Deduction to Purchase Service Credit
VRS members now select payment agreement type in myVRS and provide confirmation details page to employer. |
N/A | |
| VRS-26E |
Agreement for Pretax Salary Reduction to Purchase Service Credit
VRS members now select payment agreement type in myVRS and provide confirmation details page to employer. |
N/A | |
| VRS-45 |
Request for Health Insurance Credit
Retired participants who do not have premiums deducted from their VRS monthly benefit must complete this form. |
12-2020 | |
| VRS-48 | Request for Member Information Change | 03-2013 | |
| VRS-57 | Authorization for Direct Deposit of Monthly Benefit | 08-2019 | |
| VRS-58 |
Name and Address Declaration for Retirees
Just changing your address? Make the update using myVRS for quicker processing. |
12-2020 | |
| VRS-61 | Notification of Electronic Payment Information | 03-2018 | |
| VRS-65D | Termination Certification Form- Optional Retirement Plan for Higher Education | 09-2020 | |
| VRS-65E | Termination Certification Form - Optional Retirement Plan for Political Appointees | 09-2020 | |
| VRS-67A | Authorization of Administrative Contacts | 01-2013 | |
| VRS-70 | Request for Review of Membership Records | 02-2011 | |
| VRS-71B | Termination Certification Form - Optional Retirement Plan for School Superintendents | 09-2020 | |
| VRS-75 |
Optional Retirement Plan Health Insurance Credit Employer Certification of Service
Completed by Optional Retirement Plan participants and by their employers, who certify employment. |
12-2020 | |
| 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. |
04-2019 | |
| VRS-77 | Certification of Hazardous Duty | 02-2011 | |
| VRS-78 |
Authorization to Deduct Insurance Premiums
Completed only by employers for non-state participants. |
04-2019 | |
| VRS-83 | Certification of Eligibility to Participate in Virginia Supplemental Retirement Plan | 01-2009 | |
| VRS-160 | Certification of Eligibility for Critical Shortage Teachers and Administrators | 07-2020 | |
| VRS-160C | Certification of Eligibility for Retiree School Security Officers | 07-2020 | |
| VRS-160D | Certification of Eligibility for Critical Shortage Bus Drivers | 07-2020 | |
| VRS-170 | Authorization of Coverage Retention for the Long Term Care Plan (VSDP or VLDP) | 01-2014 | |
| VRS-171 | Protection Against Unintentional Lapse of Long Term Care (VSDP or VLDP) | 01-2014 | |
| VRS-180 | Employer Request for Forfeiture of Member Benefits | 12-2015 | |
| VRS-900 | Authorization to Discuss VRS Account Information | 02-2011 | |
| VRS-901 | VRS Durable Power of Attorney | 01-2021 |
