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Retiree 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
AC-0400Authorization Agreement for Electronic Direct DepositDownload AC-0400Request AC-0400
AC-1002Application for Duplicate CheckDownload AC-1002Request AC-1002
CL-0078Social Security Benefits and MainePERS BenefitsDownload CL-0078Request CL-0078
CL-0888Consent Form Designating Authorized RepresentativesDownload CL-0888Request CL-0888
CL-0893Affidavit for Estates Not Exceeding $40,000Download CL-0893Request CL-0893
CL-0897Cost-of-Living Adjustment Election FormDownload CL-0897Request CL-0897
GU-0002bSpecial Tax Notice Regarding Your Rollover Options Under Governmental 401(a) PlanDownload GU-0002bRequest GU-0002b
GU-1021Confidentiality Election Form - Home Contact InformationDownload GU-1021Request GU-1021
H0019How the Taxable Portion of Your Service Retirement Benefit is DeterminedDownload H0019Request H0019
H0036-1Information for Retired PLD Employees, Legislators and Judges Returning to Work Who Have Reached Normal Retirement AgeDownload H0036-1Request H0036-1
H0036-2Information for Retired State Employees and Teacher Members Returning to Work Who Have Reached Normal Retirement AgeDownload H0036-2Request H0036-2
H0036-3Information for Retired PLD Employees, Legislators and Judges Returning to Work Who Have Not Reached Normal Retirement AgeDownload H0036-3Request H0036-3
H0036-4Information for Retired State Employees and Teacher Members Returning to Work Who Have Not Reached Normal Retirement AgeDownload H0036-4Request H0036-4
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