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.
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Forms cannot be saved or altered.
| Form Number | Form Name | Download form as PDF | Request form via email |
|---|---|---|---|
| AC-0400 | Authorization Agreement for Electronic Direct Deposit | Download AC-0400 | Request AC-0400 |
| AC-1002 | Application for Duplicate Check | Download AC-1002 | Request AC-1002 |
| CL-0078 | Social Security Benefits and MainePERS Benefits | Download CL-0078 | Request CL-0078 |
| CL-0888 | Consent Form Designating Authorized Representatives | Download CL-0888 | Request CL-0888 |
| CL-0893 | Affidavit for Small Estates | Download CL-0893 | Request CL-0893 |
| CL-0897 | Cost-of-Living Adjustment Election Form | Download CL-0897 | Request CL-0897 |
| GU-0002b | Special Tax Notice Regarding Your Rollover Options Under Governmental 401(a) Plan | Download GU-0002b | Request GU-0002b |
| GU-1021 | Confidentiality Election Form - Home Contact Information | Download GU-1021 | Request GU-1021 |
| H0019 | How the Taxable Portion of Your Service Retirement Benefit is Determined | Download H0019 | Request H0019 |
| H0036-1 | Information for Retired PLD Employees, Legislators and Judges Returning to Work Who Have Reached Normal Retirement Age | Download H0036-1 | Request H0036-1 |
| H0036-2 | Information for Retired State Employees and Teacher Members Returning to Work Who Have Reached Normal Retirement Age | Download H0036-2 | Request H0036-2 |
| H0036-3 | Information for Retired PLD Employees, Legislators and Judges Returning to Work Who Have Not Reached Normal Retirement Age | Download H0036-3 | Request H0036-3 |
| H0036-4 | Information for Retired State Employees and Teacher Members Returning to Work Who Have Not Reached Normal Retirement Age | Download H0036-4 | Request H0036-4 |
| MM-0002 | Member/Benefit Recipient Data Update | Download MM-0002 | Request MM-0002 |
Federal and State Withholding Forms
| Form Number | Form Name | Download form as PDF | Request form via email |
|---|---|---|---|
| W-4P | IRS-Withholding Certificate for Pension or Annuity Payments | Download W-4P | |
| W-4ME | State of Maine - Employees Withholding Allowance Certificate | Download W-4ME | |
| CL-0905 | Non-Resident Certification for Maine Tax Withholding | Download CL-0905 | Request CL-0905 |
| W-4R | IRS-Withholding Certificate Nonperiodic Payments and Eligible Rollover Distributions. (This tax form is for Refunds and Rollover payments.) | Download W-4R |