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 Name Download Component Type
    Beneficiary Designation (VRS-2)
    To designate more than 3 beneficiaries, a continuation form, the VRS-2A, is also required.
    PDF document View DB
    Designation of Beneficiary – Continuation (VRS-2A) PDF document 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 document View DC

    Refunds & Distributions
    Form Name Download Component Type
    Request for Refund (VRS-3)
    VRS now processes refunds online. Log in to myVRS to submit your refund request.
    N/A DB
    IRS 402(f) - Special Tax Notice
    Before taking a refund, read this notice, which explains the tax consequences of taking a refund versus direct rollover into another plan.
    PDF document View DB
    Name and Address Declaration for Deferred Members (VRS-3A) PDF document View DB
    Direct Rollover/Transfer Request
    Log in to your account and download the Direct Rollover/Transfer Request Form to request a rollover or transfer from the plan.
    Login DC
    Distribution Request
    Log in to your account and select Withdrawals to request a full, partial, installment, or required minimum distribution (RMD) from your account.
    Login DC

    In-Service Distribution Request
    Log in to your account and download the In-Service Distribution Request Form to request a withdrawal from money that was previously rolled into the plan from another retirement plan.

    Login DC
    Beneficiary Claim Request Form
    This form is used by beneficiaries to claim account assets when a participant has passed away.
    PDF document View DC
    IRS Form W-4P: Withholding Certificate for Pension or Annuity Payments
    Use this form if you would like to change your tax withholding on your distribution.
    PDF document View DB, DC

    Rollovers
    Form Name Download Component Type
    Incoming Rollover Form
    Use this form to request a direct rollover of your assets from your previous employer’s retirement plan (401(a), 401(k), Governmental 457(b), 403(b), Federal Thrift Savings) to your Hybrid 457 Deferred Compensation Plan.
    PDF document View DC
    Coronavirus-Related Distribution (CRD) Repayment Form
    Use this form to repay your CRD within three years of taking the distribution.
    PDF document View DC

    Account Authorization
    Form Name Download Component Type
    Authorization to Discuss VRS Account Information (VRS-900) PDF document View DB
    Durable Power of Attorney (VRS-901) PDF document View DB
    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 document View DC

    Forms

    Other VRS Forms
    Form Name Download Component  Type
    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.
    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)
    Before completing the form, log in to myVRS for retirement counseling resources and review the Apply for Retirement page to determine if you can retire online.
    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)
    VRS members now select payment agreement type in myVRS and provide confirmation details page to employer.
    N/A DB
    Agreement for Pre-Tax Salary Reduction to Purchase Service Credit (VRS-26E)
    VRS members now select payment agreement type in myVRS and provide confirmation details page to employer.
    N/A DB
    Application for Contribution Make-Up for Hybrid Plan Participants Returning from Military Leave (VRS-26M) PDF icon View DC
    Request for Health Insurance Credit (VRS-45) PDF icon View DB
    Approved Domestic Relations Orders - Defined Benefit Plan
    The Code of Virginia authorizes VRS to make a direct payment to a former spouse if the court awards your former spouse part of your benefit. In this situation, provide this form to your attorney to submit.
    PDF icon View DB
    Approved Domestic Relations Orders - Defined Contribution Account(s)
    The Code of Virginia authorizes VRS to make a direct payment to a former spouse if the court awards your former spouse part of your benefit. In this situation, provide this form to your attorney to submit.
    PDF icon View DC
    Authorization for Direct Deposit of Monthly Benefit (VRS-57) PDF icon View DB
    Name and Address Declaration for Retirees (VRS-58) 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
    partial VRS

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