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Department of State Treasurer | NC Retirement Systems Home
Online Retirement Benefits Through Integrated Technology
LIST OF ALL FORMS
  Return To Retirement Systems Division Forms.
 

All forms for members are listed here, but not all are available through this website. In some cases, you may need to see your employer for the form or for a sample of it. In certain cases, the Retirement Systems Division only provides the forms upon request

 
 
Form no.Form Description
 
Form 111S
 
111S-Summarizing Contributions From Employees and Employers
 
Form 11S
 
11S-Monthly Remittance of Fees for the Registers of Deeds' Supplemental Pension Fund
 
Form 170
 
170-Authorizing Direct Deposit
 
Form 170401k
 
170401k-Authorizing 401K Direct Deposit
 
Form 170457
 
170457-Authorizing 457 Direct Deposit
 
Form 170S
 
170S-Survivor's Benefit: Authorizing Direct Deposit
 
Form 237
 
237-Reporting Your 2013 Income To Continue Your Retirement System Disability Benefit
 
Form 253
 
253-Reporting an Employee's Work Record In the Event of Death
 
Form 276
 
276-Designating Beneficiary(ies) for the Separate Insurance Benefit Plan for Law Enforcement
 
Form 290
 
290-Choosing Income Tax Withholding Preferences
 
Form 290401k
 
290401k-Choosing 401K Income Tax Withholding Preferences
 
Form 290457
 
290457-Choosing 457 Income Tax Withholding Preferences
 
Form 290S
 
290S-Survivor's Benefit: Choosing Income Tax Withholding Preferences
 
Form 296
 
296-Reporting Your 2013 Income To Continue Your Benefit Through the Disability Income Plan
 
Form 297
 
297-Reporting Your 2013 Income to Continue Your Disability Salary Continuation Plan Benefit
 
Form 2DB
 
2DB-Designating Beneficiary(ies) for the Death Benefit
 
Form 2RC
 
2RC-Designating Beneficiary(ies) for Retirement System Return of Contributions
 
Form 309
 
309-Estimating Your Service Retirement Benefits
 
Form 316
 
316-Pink Sheet Refund
 
Form 319401k
 
319401k-Choosing to Transfer NC401(k) Plan Contributions for an Additional Monthly Benefit
 
Form 319457
 
319457-Choosing to Transfer NC Deferred Compensation (457) Plan Contribs for an Additional Monthly Benefit
 
Form 319LEO
 
319LEO-Choosing to Transfer NC401(k) Plan Contributions for an Additional Monthly Benefit for LEOs
 
Form 333sample
 
333sample-Choosing the Contributory Death Benefit for Retired Members
 
Form 336
 
336-Designating Beneficiary(ies) for the Guaranteed Refund as a Retiree
 
Form 336401k
 
336401k-Designating Beneficiary(ies) for the 401K Guaranteed Refund
 
Form 336457
 
336457-Designating Beneficiary(ies) for the 457 Guaranteed Refund
 
Form 348
 
348-Requesting Leave of Absence in the Firemen's and Rescue Squad Workers' Pension Fund
 
Form 349
 
349-Purchasing Pension Fund Credit for Prior Fire or Rescue Service
 
Form 350
 
350-Enrolling in the Firefighters' and Rescue Squad Workers' Pension Fund
 
Form 359
 
359-Transferring Accounts in the Firefighters' and Rescue Squad Workers' Pension Fund
 
Form 398
 
398-Using A Distribution of Tax-Sheltered Savings to Purchase Retirement Credit
 
Form 430
 
430-Purchasing Retirement Credit for a Period of Interrupted Service Related to Parental Leave
 
Form 432
 
432-Purchasing Retirement Credit for a Period of Interrupted Service Due to Involuntary Furlough
 
Form 441
 
441-Purchasing Retirement Credit for a Period of Workers’ Compensation
 
Form 443
 
443-Purchasing Retirement Credit for State or Local Government Temporary Employment
 
Form 451
 
451-Purchasing Retirement Credit for a Period of Part-Time State or Local Government Employment
 
Form 452
 
452-Purchasing Retirement Credit for a Period of Service with a Non-Participating Local Unit
 
Form 455
 
455-Purchasing Retirement Credit for a Period of Out-of-State Employment
 
Form 461
 
461-Purchasing Retirement System Credit for Withdrawn Service
 
Form 462
 
462-Purchasing Retirement System Credit for Military Service
 
Form 463
 
463-Purchasing Retirement Credit for a Period of Interrupted Service for Educational Purposes
 
Form 463F
 
463F-Requesting Continuation of Contributions and Credit for Planned Educational Leave
 
Form 466
 
466-Purchasing Retirement System Credit for Unreported Service Omitted Through Error
 
Form 467
 
467-Purchasing Retirement System Credit for a Period of Federal Service
 
Form 470
 
470-Purchasing Retirement Credit for a Waiting Period Imposed by a Local Unit
 
Form 478
 
478-Purchasing Retirement System Credit for Withdrawn Optional Retirement Program Service
 
Form 479
 
479-Purchasing Retirement System Credit for a Period of Federally-Funded Service
 
Form 481
 
481-Purchasing Retirement Credit for a Period of Service Not Credited by the Former LEORS
 
Form 485
 
485-Purchasing Retirement Credit for a Period of Interrupted Service Due to Extended Illness
 
Form 499
 
499-Purchasing Retirement Credit for a Period of Service with a Non-Participating Charter School
 
Form 5
 
5-Withdrawing Your Retirement Service Credit and Contributions
 
Form 5FR
 
5FR-Withdrawing Contributions from the Firefighters' and Rescue Squad Workers' Pension Fund
 
Form 5ROCsample
 
5ROCsample-Choosing the Return of Contributions
 
Form 5TRsample
 
5TRsample-Transferring Service and Contributions Between Systems
 
Form 6
 
6-Claiming Your Retirement Benefit
 
Form 6C
 
6C-Reporting an Employee's Work Record for Retirement
 
Form 6EJsample
 
6EJsample-Choosing Your Retirement Payment Option for the Consolidated Judicial Retirement System
 
Form 6ELsample
 
6ELsample-Choosing Your Retirement Payment Option for the Legislative Retirement System
 
Form 6ERsample
 
6ERsample-Authorizing Your New Spouse As Beneficiary
 
Form 6Esample
 
6Esample-Choosing Your Retirement Payment Option
 
Form 6FR
 
6FR-Retiring from the Firefighters' and Rescue Squad Workers' Pension Fund
 
Form 6SABsample
 
6SABsample-Choosing the Survivor's Alternate Benefit
 
Form 7
 
7-Requesting Disability Retirement Benefits
 
Form 700
 
700-Required Employer Information
 
Form 701
 
701-Requesting the Short-Term of Benefits through the Disability Income Plan of North Carolina
 
Form 702
 
702-Reporting Earnings to Your Employer During the Short Term
 
Form 703
 
703-Medical Report for Eligibility Review of Short-Term Disability Benefits
 
Form 704
 
704-Requesting Additional Benefits through the Disability Income Plan of North Carolina
 
Form 705
 
705-Agreeing to Accept Long-Term Benefits through the Disability Income Plan of N.C.
 
Form 706
 
706-Confirming an Employee's Resignation
 
Form 707
 
707-Reporting Earnings Monthly While Receiving Extended Short-Term or Long-Term Benefits
 
Form 709
 
709-Estimating Your Disability Retirement Benefits
 
Form 710
 
710-Employer's Worksheet for Determining the Waiting Period Before the Short Term Begins
 
Form 711
 
711-Determining the Maximum Monthly Benefit During the Short Term
 
Form 712
 
712-(Optional) Determining the Affect of Other Benefits on the Short-Term Benefit
 
Form 713
 
713-(Optional) Determining the Short-Term Benefit for Partial and Special Months
 
Form 714
 
714-Employer's Payment Record, Reimbursement Calculation, and Service Credit Report
 
Form 7A
 
7A-Medical Report for Disability Eligibility Review
 
Form 7AR
 
7AR-Medical Report for Re-exam
 
Form 7E
 
7E-Choosing Your Disability Retirement Payment Option
 
Form 7FR
 
7FR-Requesting Disability Status from the Firefighters' and Rescue Squad Workers' Pension Fund
 
Form COA
 
COA-Updating Your Addresses or Name
 
Form DB228
 
DB228-Choosing Tax Treatment for a Payment of Undistributed Contributions Due to a Death
 
Form ERRWK
 
ERRWK-Correcting an Employee's Payroll Record
 
Form ESRR
 
ESRR-Certifying Employee Status Under Retirement Reemployment Laws
 
Form HMOnline
 
HMOnline-Instructions for Changing Retiree Health Coverage Through the State Health Plan Online
 
Form HMOnlineIn
 
HMOnlineIn-Instructions for filling out HMOnlineIn
 
Form MR
 
MR-Authorizing the Release of Medical Records
 
Form ORP
 
ORP-Certifying Optional Retirement Program (ORP) Service Credit Under TSERS Reciprocity Provisions
 
Form SA
 
SA-Employer's Review of an Employee's Record of Service
 
Form SVC
 
SVC-Reviewing Your Service Record and Requesting an Audit of Your Service Credit