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)
Update beneficiaries online through your secure myVRS account.
N/A DB
Beneficiary Designation
Log in to choose or change the designated beneficiary for your account. This will ensure an immediate update to your beneficiary information.
Login 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.
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
Workforce Transition Act (WTA) Distribution/Rollover Request Form
Log in to your account and download the Workforce Transition Act (WTA) Distribution/Rollover Request Form if you have separated employment and are receiving benefits under WTA.
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 (A10601) PDF icon View DB
College and University Opt-Out Form (VSDP-2) PDF icon View DB
Name and Address Declaration for Deferred Members (VRS-3A) 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)
Retirees can update direct deposit information online through myVRS.
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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