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Maine Public Employees Retirement System
P.O. Box 349, Augusta, ME 04332-0349
toll free: (800) 451-9800 ● local: (207) 512-3100

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Group Life Insurance
Forms - Retirement Benefits
Forms may be downloaded by clicking the corresponding form number below. The "Request Forms" e-mail is for ordering hardcopy forms only. 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.

Package Service Retirement Application Package Request Package
H0046 Service Retirement Application Timeline  
CL-0715+ Application For Service Retirement Benefits Request Form
CL-0901+ CARES ACT Refund Certification Request Form
Package Refund Application Package Request
H0027 Additional Service Retirement Information  
H0051 Alternate Payee Benefit Inception Information  
AC-0400+ Authorization Agreement for Electronic Direct Deposit Request Form
CL-0902 CARES Act Rollover/Direct Transfer Certification Form (For purchase of service credit) Request Form
CL-0875 Certification of Bona Fide Termination Request Form
CL-0704B Certificate of Out-of-State Teaching Service Request Form
CL-0898+ Certificate of Service in Law Enforcement Request Form
CL-0718+ Certification of Spousal Notification Request Form
CL-0704 Certificate of Teaching Service in Maine Public Schools Request Form
CL-0704A Certificate of Teaching Service in Public or Private Academies, or Parochial Schools Request Form
CL-0897+ Cost-of-Living Adjustment Election Form Request Form
CL-0719+ Information Regarding Restoration to Service (Election Form) for
PLDs with Social Security
Request Form
MM-0002+ Member/Benefit Recipient Data Update Request Form
AC-0003+ Rollover / Direct Transfer Request / Certification Form (For purchase of service credit) Request Form
CL-0078 Social Security Benefits and the MainePERS Benefits Request Form
State of Maine Forms  
W-4P Withholding Certificate for Pension or Annuity Payments  
W-4ME Employees Maine Withholding Allowance Certificate  

+ Forms indicated with "+" may be viewed and completed on the screen using a recent version of Adobe® Reader®, printed, and mailed to the MainePERS. You may click on any line to complete that area or use TAB to move forward and SHIFT-TAB to move back. Forms cannot be saved or altered.

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Information contained on this Web site is neither a legal reference nor a complete statement of the laws or MainePERS administrative rules. In any conflict between this information and Maine laws or administrative rules, the laws and administrative rules shall prevail.

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