Chapter 17 FRS FORMS. Chapter 17 Contents:

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1 Chapter 17 FRS FORMS Chapter 17 Contents: I. Administrative s II. s of the Bureau of Enrollment and Contributions III. s of the Bureau of Retirement Calculations IV. s of the Bureau of Benefit Payments A. Disability Determination B. Survivor Benefits C. Retired Payroll D. DROP Termination V. s This chapter lists the forms used by the Division of Retirement. To obtain copies of most of the forms listed in this chapter, please contact the appropriate Bureau to request the form or forms you need. (Investment Plan forms listed exclusively on page are available online.) CHAPTER 17: FRS FORMS

2 FLORIDA RETIREMENT SYSTEM EMPLOYER HANDBOOK Contact Us for s Contact information for each Bureau is published below: Bureau of Enrollment and Contributions: (850) / SUNCOM enrollment@frs.state.fl.us FAX #: (850) Bureau of Retirement Calculations: (850) / SUNCOM calculations@frs.state.fl.us FAX #: (850) Bureau of Benefit Payments: (850) / SUNCOM retired@frs.state.fl.us FAX #: (850) Disability Determination Section: (850) / SUNCOM disability@frs.state.fl.us FAX #: (850) DROP Termination Section: (850) / SUNCOM drop_term@frs.state.fl.us FAX #: (850) Survivor Benefits Section: (850) / SUNCOM survivor@frs.state.fl.us FAX #: (850) Sample s & s Published Online Samples of the most commonly used forms are shown throughout the chapters of this handbook 1. A number of the forms listed in this chapter are also available on the Division s Internet web site at or from the joint website of the Division and the State Board of Administration at: (select the Resources Tab). s available on the Internet are indicated by the symbol. NOTE: Completed forms may be mailed or faxed to the Division. If you fax us a signed and/or notarized form you must retain the original form. You do not need to mail the original to us, unless requested. 1 Samples are not included in the handbook for forms marked with an asterisk (*) (Sep 2004) CHAPTER 17.

3 Chapter 17: FRS FORMS I. ADMINISTRATIVE FORMS Number Title/Subject of Page SAPS Statement Attesting to Payee Status * [none] Publications Request 16-7 II. FORMS OF THE BUREAU OF ENROLLMENT AND CONTRIBUTIONS Number Title/Subject of Page BEN-001 BLE-1 Beneficiary Designation (Active Members Only) [Note: Not for DROP participants] 1-66 Ballot for Member of an Existing Retirement System 1-13 CERT New Employee Certification ELE-1-EZ ELE-2-EZ ELE-1 ELE-2 EOC-1 ERQ-1 FRS-400 FRS-401 FRS-402 EZ Retirement Plan Enrollment for Regular, Special Risk and Special Risk Administrative Support Class Employees * 2nd Election EZ Retirement Plan Enrollment * GENERAL Retirement Plan Enrollment for Regular, Special Risk and Special Risk Administrative Support Class Employees * 2nd Election Retirement Plan Enrollment * Elected Officers Class Employees Retirement Plan Enrollment 1-33 Employment Relationship Questionnaire * Application for Special Risk Membership Law Enforcement/Correctional Officers 1-23 Special Risk Credit for Past Service * Application for Special Risk Equivalent Credit * Part I. ADMINISTRATIVE FORMS (Sep 2004) 17-3

4 FLORIDA RETIREMENT SYSTEM EMPLOYER HANDBOOK FRS-404 FRS-405 OCC-1 OCC-2 [Online] [Online] [Online] ORP-16 ORP-16A SMS-1 SMS-3 SMSD-1 SRC-001 Application for Special Risk Administrative Support Class 1-27 Application for Special Risk Membership Firefighters/Paramedics/EMTs 1-24 Ballot/Enrollment for Community Colleges Optional Retirement Program Employees 1-57 Retirement Plan Conversion for Community College Optional Retirement Program (CCORP) Members 1-58 FRS Contributions Summary : (Retirement/HIS) only 2-25 Optional Annuity Program Contributions Summary only 2-29 Optional Retirement Program (ORP/IFAS) Contributions Summary only 2-27 State University System Optional Retirement Program (SUSORP) FRS Ballot 1-47 State University System Optional Retirement Program (SUSORP) Change 1-48 State Senior Management Service Employees Retirement Plan Enrollment 1-39 Local Senior Management Service Employees Retirement Plan Enrollment 1-40 Senior Management Service Class Designated Position 1-42 Petition for Administrative Hearing before the State Retirement Commission * 17-4 (Sep 2004) CHAPTER 17.

5 Chapter 17: FRS FORMS III. I. FORMS OF THE BUREAU OF RETIREMENT CALCULATIONS Number BVR-1 DP-11 DP-ELE DP-EXT DPR-100 DS-11 DT-11 ER-TERM FC-1 FR-9 FR-11 FR-23 FR-23a FR-28 Title/ Subject of Page Request for Proof of Age (Birth Verification ) * Application for Service Retirement and the Deferred Retirement Option Program (DROP) 9-45 Notice of Election to Participate in the Deferred Retirement Option Program (DROP) and Resignation of Employment 9-44 Extension of Deferred Retirement Option Program (DROP) for Specified K-12 Instructional Personnel 9-46 Certification of Salaries * State and County Officers and Employees Retirement System Application for Service Retirement and the Deferred Retirement Option Program (DROP) * Application for Service Retirement and the Deferred Retirement Option Program (DROP) * Agency Termination Verification for Service Retirements and Health Insurance Subsidy * Salary Certification 9-19 Information Request 7-6 Application for Service Retirement 9-10 Notification of Reemployment for Suspension of Retirement Benefits (For Retired Members Only) 13-5 Application to Reactivate Retirement Benefits (For Retired Members Only) 13-6 Division of Retirement Pension Plan Application to Purchase Retirement Credit for a Pension Plan Leave of Absence 7-21 Part III. FORMS OF THE BUREAU OF RETIREMENT CALCULATIONS (Sep 2004) 17-5

6 FLORIDA RETIREMENT SYSTEM EMPLOYER HANDBOOK FR-30 FR-30a FRS-11o FST-11o FST-12 HIS-IP HIS-IP-2 IF-11 MF-1 MF-2 OSE-1 PRO-1 SA-1 SR-11 TR-11 TR-4 WC-1 Verification for In-State or Out-of-State Service Credit 7-27 to 7-28 Out-of-State Employer Request * Option Selection for FRS Members 9-14 Option Selection for TRS and SCOERS Members * Beneficiary Designation (Retired Members Only) 9-17 Application for Health Insurance Subsidy for Investment Plan Members * Health Insurance Subsidy Certification for Investment Plan Members * Institute of Food and Agricultural Sciences Application for IFAS Supplemental Retirement * Statement of Military Eligibility 7-15 Statement of Military Eligibility to Purchase Military Service under the Out-of-State Provisions of Section , F.S Eligibility for Out-of-State Credit * (401(a) Plan) Pretax Direct Rollover/Transfer 7-7 Spousal Acknowledgment * State and County Officers and Employees Retirement System Application for Service Retirement * Application for Service Retirement * Verification of Out-of-State Teaching Service * Certification of Workers Compensation (Sep 2004) CHAPTER 17.

7 Chapter 17: FRS FORMS IV. FORMS OF THE BUREAU OF BENEFIT PAYMENTS A. DISABILITY DETERMINATION Number Title/Subject of Page FC-1 FR-13 FR-13a FR-13b FR-13e FR-13f FRS-11o FST-12 PR-11o PR-13 SB-13b SR-13 SR-13a SR-13b SR-13e SR-13f Salary Certification 9-19 Application for Disability Retirement 10-8 to 10-9 Statement of Disability by Employer to Physician s Report to Retiree s Report of Continuing Disability * Physician s Report of Reexamination * Option Selection for FRS Members 9-14 Beneficiary Designation (Retired Members Only) [Note: Includes DROP participants] 9-17 Investment Plan Option Selection for FRS Members Investment Plan Application for Disability Retirement to Physician's Report (Disability Determination for Joint Annuitant) * State and County Officers and Employees Retirement System (SCOERS) Application for Disability Retirement * State and County Officers and Employees Retirement System (SCOERS) Member s Statement of Disability by Employer * State and County Officers and Employees Retirement System (SCOERS) Physician s Report * State and County Officers and Employees Retirement System (SCOERS) Retiree s Report of Continuing Disability * State and County Officers and Employees Retirement System (SCOERS) Physician s Report of Reexamination * Part IV. FORMS OF THE BUREAU OF BENEFIT PAYMENTS: A. DISABILITY DETERMINATION (Sep 2004) 17-7

8 FLORIDA RETIREMENT SYSTEM EMPLOYER HANDBOOK SRA-1 SRC-001 TR-13 TR-13a TR-13b TR-13e TR-13f Service Retirement Agreement * Petition for Administrative Hearing before the State Retirement Commission * Application for Disability Retirement * Statement of Disability by Employer * Physician s Report * Retiree s Report of Continuing Disability * Physician s Report of Reexamination * B. SURVIVOR BENEFITS Number Title/Subject of Page AAPS BVR-1 DIS-1 DIS-2 DIS-3 DOCEV DP-12 DROLL FC-1 Affidavit Attesting to Payee Status * Request for Proof of Age (Birth Verification ) * Disclaimer of Benefits (Surviving Beneficiary) * Disclaimer of Benefits (Surviving Child) * Disclaimer of Benefits (Surviving Beneficiary and Child) * Explanation of Documentary Evidence * Beneficiary Designation for the Alternate Payee of a DROP Participant * Beneficiary Direct Rollover Election * Salary Certification (Sep 2004) CHAPTER 17.

9 Chapter 17: FRS FORMS FR-30b FRS-11o FST-11b FST-11g FST-11so2 FST-12 JA-1 JA-NUL JAD-SB MF-1 SB-13b SRF-2 SRF-3 SVF-1 SVF-2 TAXPREF TR-11c Verification for In-State or Out-of-State Service Credit * Option Selection for FRS Members 9-14 Application of Beneficiary for Monthly Retirement Benefits Application of Beneficiary for Benefit Payment Application for Survivor Benefits * Beneficiary Designation (Retired Members Only) [Note: Includes DROP participants] 9-17 Change of Joint Annuitant (Retired members only) 11-5 Joint Annuitant Nullification 11-6 Joint Annuitant Information * Statement of Military Eligibility 7-15 Physician's Report (Disability Determination for Joint Annuitant) * Student Report * Authorization for Release of Information * Student Verification of Enrollment by Institution * Affidavit Attesting to Eligibility * Special Notice Regarding Plan Payments (information on rollovers) * Application for Survivor Benefits * Part IV. FORMS OF THE BUREAU OF BENEFIT PAYMENTS: B. SURVIVOR BENEFITS (Sep 2004) 17-9

10 FLORIDA RETIREMENT SYSTEM EMPLOYER HANDBOOK C. RETIRED PAYROLL Number Title/Subject of Page 1099-R Information for Reporting Taxes on Retirement Income [Income Tax Reporting of the Internal Revenue Service] * ADDCH-1 DFS-A1-26R FRS-M81 HIS-1 HISBAL IDAF RAS Rollover W-4P Mailing Address Change Request (Retirees Only) * State of Florida Direct Deposit Authorization [ of the Department of Financial Services] * Request for Refund 8-4 Health Insurance Subsidy Certification 12-7 Certification of Retirees 2003 Health Insurance Premium Payments * Insurance Deduction Authorization * Retiree Annual Statement * Direct Rollover Election * Withholding Certificate for Pension Payments * (Sep 2004) CHAPTER 17.

11 Chapter 17: FRS FORMS D. DROP TERMINATION UNIT Number Title/Subject of Page DP-JOINT DP-PAYT DP-TEOC DP-TERM DP-VOID Deferred Retirement Option Program (DROP) Joint Annuitant Verification * Deferred Retirement Option Program (DROP) Selected Payout Method 9-48 Deferred Retirement Option Program (DROP) Elected Officers Termination Notification * Deferred Retirement Option Program (DROP) Termination Notification Deferred Retirement Option Program (DROP) Void * 9-47 Part IV. FORMS OF THE BUREAU OF BENEFIT PAYMENTS: D. DROP TERMINATION UNIT (Sep 2004) 17-11

12 FLORIDA RETIREMENT SYSTEM EMPLOYER HANDBOOK V. FRS INVESTMENT PLAN FORMS 2 Number Title/Subject of Page CP-1 ETF-2 HIS-IP HIS-IP-2 IPBEN-1 IPBI IPDB IPDF IPRO-1 Notice How to File a Complaint under the Frs Investment Plan * Employment Termination * Application for Health Insurance Subsidy for Investment Plan Members 12-8 Health Insurance Subsidy Certification for Investment Plan Members 12-9 Beneficiary Designation * Death Benefit Distribution Instructions and Options * Death Benefit Distribution Claim * Age 70½ Distribution * Employee Rollover Deposit * Special Tax Notice Retirement Savings and Stock Ownership Plan Payments * 2 Except for s HIS-IP and HIS-IP-2 (see page 17-6), investment plan forms listed on this page are forms of the Florida State Board of Administration and are available online only (Sep 2004) CHAPTER 17.