Employer Forms

Contact Change Request

In order to complete the forms properly in .PDF Format, you must have Adobe's Acrobat Reader installed on your computer. If you don't already have this utility, you can download a free copy from Adobe's website by clicking on the Acrobat Reader icon below. Download the form and open it in Adobe Acrobat to complete.

Employers Forms

Adult Dependent Coordination of
Benefits Information

Application for Withdrawal of Benefits
(Form WB-1) Contribution Retention Notice
(Form CRN-1) Creditable Service Form
(Form CSE-1) $7000 Burial Benefit Designation / Change of
Beneficiary Form (Form GL) Designation/Change of Beneficiary for Pension Contributions
(Form BEN-1) Dental Insurance Application
or Refusal Deposit Authorization Form
(Form DA) Vision Insurance Application
or Refusal Healthcare Application
Special Medicfill Medicare Health Plan
Waiver/Termination Healthcare Application:
Aetna/Highmark Joint Survivor Beneficiary Form
(Form JSB-1) New Hire Actuarial Form
(Form P-1) Instructions for Completing
PCC-1 Form - Agency Pension Creditable Compensation
(Agency) (Form PCC-1)

Spousal Coordination of
Benefits Information

Instructions for Completing
PCC-1 Form - Schools Pension Creditable Compensation
(School) (Form PCC-1)

Tax Forms

Pensioners may request that Federal and Delaware state taxes be withheld from their retirement monthly pension benefit. The Office of Pensions does not withhold state taxes for any state other than Delaware.

IRS W-4P Form

State of Delaware W4

The Office of Pensions staff cannot provide tax advice. If you have specific questions regarding taxes, you may wish to consult with a qualified tax adviser.

Social Security Forms

Medicare Part B Application
(CMS-40B) Request for Employment Information
(CMS L564/R297) Medicare Resource Guide

Bundled Forms

Health Care Forms
Zipped Bundle

Payroll Forms
Zipped Bundle

Employee Retirement
Zipped Packet

Pension Application Forms (2nd Retirements and Diamond State Port Only)

State Employees’ Pension Plan
Application for Pension Other Pension Plans
Application for Pension