Hybrid Retirement Plan: Helping You Plan for Tomorrow, Today

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    Forms

    Beneficiary Designation | Refunds & Distributions | Rollovers | Account Authorization | Other VRS Forms

    Important: Most forms do not apply to both components of the Hybrid Retirement Plan. Use the third column to determine if the form is needed for the Defined Benefit (DB) or Defined Contribution (DC) component.

    Beneficiary Designation
    Note: Beneficiaries must be designated separately for both components.
    Form NameDownloadComponent Type
    Beneficiary Designation (VRS-2)
    To designate more than 3 beneficiaries, a continuation form, the VRS-2A, is also required.
    PDF icon View DB
    Designation of Beneficiary – Continuation (VRS-2A) PDF icon View DB
    Beneficiary Designation
    You can also log in to your account and complete this online to ensure an immediate update to your beneficiary information.
    PDF icon View DC

    Refunds & Distributions
    Form NameDownloadComponent Type
    Defined Benefit Plan Request for Refund (VRS-3)
    You MUST read the IRS 402(f) Special Tax Notice before filling out this form.
    PDF icon View DB
    Name and Address Declaration for Deferred Members (VRS-3A) PDF icon View DB
    VRS Hybrid 457 Deferred Compensation Plan Distribution/Direct Rollover/Transfer Request PDF icon View DC
    VRS Hybrid 401(a) Cash Match Plan Distribution/Direct Rollover/Transfer Request PDF icon View DC
    Beneficiary Claim Request PDF icon View DC
    IRS Form W-4P: Withholding Certificate for Pension or Annuity Payments PDF icon View DC

    Rollovers
    Form NameDownloadComponent Type
    Hybrid 457 Incoming Transfer/Rollover Form PDF icon View DC

    Account Authorization
    Form NameDownloadComponent Type
    Authorization to Discuss VRS Account Information (VRS-900) PDF icon View DB
    Durable Power of Attorney (VRS-901) PDF icon View DB
    Account Access Code
    This form is used in special situations in which an additional security level is needed when contacting Investor Services. Review the instructions for more details.
    PDF icon View DC
    Information Release Authorization
    Use this form to authorize a third party to obtain information regarding your account. Please note that it does not authorize this individual to conduct transactions on your behalf.
    PDF icon View DC

    Forms

    Other VRS Forms
    Form Name Download Component  Type
    Minnesota Life/VRS Life Insurance Forms Page PDF icon View DB
    VRS Certificate of Life Insurance PDF icon View DB
    State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants (T-20879) PDF icon View DB
    College and University Opt-Out Form (VSDP-2) PDF icon View DB
    Application for Retirement (VRS-5) PDF icon View DB
    Request for Income Tax Withholding (VRS-15) PDF icon View DB
    Application for Purchase of Prior Service Credit (VRS-26) PDF icon View DB
    Authorization for After-Tax Payroll Deduction to Purchase Service Credit (VRS-26C) PDF icon View DB
    Agreement for Pre-Tax Salary Reduction to Purchase Service Credit (VRS-26E) PDF icon View DB
    Application for Contribution Make-Up for Hybrid Plan Participants Returning from Military Leave (VRS-26M) PDF icon View DB
    Accidental Dismemberment and Loss of Sight (VRS-31) PDF icon View DB
    Group Life Evidence of Insurability (VRS-32) PDF icon View DB
    Conversion of Group Life Insurance Enrollment (VRS-35E) PDF icon View DB
    Absolute Assignment of Group Life Insurance (VRS-37) PDF icon View DB
    Assignees Change of Beneficiary (VRS-38) PDF icon View DB
    Application for Optional Life Insurance (VRS-39) PDF icon View DB
    Request for Change Under Optional Group Life Insurance Plan (VRS-39A) PDF icon View DB
    Retiree Optional Life Continuation (VRS-39R) PDF icon View DB
    Request for Health Insurance Credit (VRS-45) PDF icon View DB
    Authorization for Direct Deposit of Monthly Benefit (VRS-57) PDF icon View DB
    Request for Estimate of Retirement Benefits (VRS-60) PDF icon View DB
    Request for Review of Membership Records (VRS-70) PDF icon View DB
    Authorization of Coverage Retention for the Long Term Care Plan (VSDP or VLDP) (VRS-170) PDF icon View DB
    Protection Against Unintentional Lapse of Long Term Care (VSDP or VLDP) (VRS-171) PDF icon View DB
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