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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.

Forms
Form #DescriptionLast UpdatedDownload
N/A Approved Domestic Relations Orders - Defined Benefit Plan 08/2019
N/A Approved Domestic Relations Orders - Defined Contribution Account(s) 08/2019
ALL Hybrid Forms for Members
ALL Hybrid Forms for Employers
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.
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.
12/2018
T-20879 State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants 03/2019
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.
09/2019
VRS-2A Designation of Beneficiary - Continuation 09/2019
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 08/2019
VRS-6 Application for Disability Retirement 04/2019
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 04/2019
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 10/2018
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.
 
VRS-26E Agreement for Pre-Tax Salary Reduction to Purchase Service Credit
VRS members now select payment agreement type in myVRS and provide confirmation details page to employer.
 
VRS-45 Request for Health Insurance Credit
Retired participants who do not have premiums deducted from their VRS monthly benefit must complete this form.
04/2019
VRS-48 Request for Member Information Change 03/2013
VRS-49 Change to Certification for Retirement
This form is no longer required. Employers make certification changes directly in myVRS Navigator.
 
VRS-57 Authorization for Direct Deposit of Monthly Benefit 08/2019
VRS-58 Name and Address Declaration For Retirees 03/2013
VRS-61 Notification of Electronic Payment Information 03/2018
VRS-65D Termination Certification Form- Optional Retirement Plan for Higher Education 01/2017
VRS-65E Termination Certification Form - Optional Retirement Plan for Political Appointees 01/2017
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 01/2017
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.
04/2019
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 04/2010
VRS-160A Certification of Non-Participation of Critical Shortage Teachers and Administrators 04/2013
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 10/2019

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