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Member Forms

Forms may be downloaded by clicking the download links below. To request hardcopy forms, please send an email request via the link in the “Request form via email” column next to the form name. For all other inquiries, please contact MainePERS directly. 

To use these forms you will need Adobe Reader®.  If you don’t have Reader, you can get it free by clicking the Adobe link above. For information on completing forms with Reader® click here.

Forms cannot be saved or altered.

Form NumberForm NameDownload form as PDFRequest form via email
PackageService Retirement Application PackageDownload PackageRequest Service Retirement Application Package
PackageRefund Application PackageDownload PackageRequest Refund Application Package
AC-0003Rollover / Direct Transfer Request / Certification Form (For purchase of service credit) Download AC-0003Request AC-0003
AC-0400Authorization Agreement for Electronic Direct DepositDownload AC-0400Request AC-0400
CL-0078Social Security Benefits and MainePERS BenefitsDownload CL-0078Request CL-0078
CL-0704Certificate of Teaching Service in Maine Public SchoolsDownload CL-0704Request CL-0704
CL-0704ACertificate of Teaching Service in Public or Private Academies, or Parochial SchoolsDownload CL-0704ARequest CL-0704A
CL-0704BCertificate of Out-of-State Teaching ServiceDownload CL-0704BRequest CL-0704B
CL-0715Application For Service Retirement BenefitsDownload CL-0715Request CL-0715
CL-0718Certification of Spousal NotificationDownload CL-0718Request CL-0718
CL-0719Information Regarding Restoration to Service (Election Form) for PLDs with Social SecurityDownload CL-0719Request CL-0719
CL-0722Designation of Beneficiary Pre-Retirement Death Benefits
(Individuals completing this form might also consider completing the Designation of Beneficiary Group Life Insurance form.)
Download CL-0722Request CL-0722
CL-0722AInformation Regarding Designation of Beneficiary Pre-Retirement Death BenefitsDownload CL-0722ARequest CL-0722A
CL-0875Certification of Bona Fide TerminationDownload CL-0875Request CL-0875
CL-0897Cost-of-Living Adjustment Election FormDownload CL-0897Request CL-0897
CL-0898Certificate of Service in Law EnforcementDownload CL-0898Request CL-0898
CL-0901CARES ACT Refund CertificationDownload CL-0901Request CL-0901
H0027Additional Service Retirement InformationDownload Additional Service Retirement Informationn/a
H0046Service Retirement Application TimelineDownload Service Retirement Application Timelinen/a
H0051Alternate Payee Benefit Inception InformationDownload Alternate Payee Benefit Inception Informationn/a
MM-0002Member/Benefit Recipient Data UpdateDownload MM-0002Request MM-0002

Federal and State Withholding Forms

Form NumberForm NameDownload form as PDF
W-4PIRS-Withholding Certificate for Pension or Annuity PaymentsDownload W-4P
W-4MEState of Maine - Employees Witholding Allowance CertificateDownload W-4ME