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Administrative Forms

These forms are only intended for use by employer-sponsored plans who utilize PA Retirement Solutions, Inc. as their Third Party Administrator.  Please also note that some investment providers require their own forms to be completed for all distribution and loan requests.  If you are not sure if these forms are right for you, please contact PA Retirement Solutions, Inc. or your Employer/Plan Administrator before completing and returning for processing.

Beneficiary Form                                                                  
For use by participants to designate their primary and contingent beneficiary(ies).  All participants should have a completed and up to date beneficiary form on file with their Employer/Plan Sponsor.

  PDF Version - Click Here Word Fill-In Version - Click Here

Deferral Percentage Change Form – without Roth          
For use by participants to elect a change to the amount or percentage currently being deferred to the plan.  Election changes must be made in accordance with plan provisions.  Please refer to the plan’s SPD for more information.

  PDF Version - Click Here Word Fill-In Version - Click Here

Deferral Percentage Change Form – with Roth
For use by participants to elect a change to their deferral percentage or dollar amount to plans that allow Roth deferrals.  Election changes must be made in accordance with plan provisions.  Please refer to the plan’s adoption agreement or SPD for more information on availability in your plan.

  PDF Version - Click Here Word Fill-In Version - Click Here

Special Tax Notice
This document is required to be furnished to all participants receiving a distribution from the Plan. 

  PDF Version - Click Here  

Normal Withdrawal Form  
For use by participants electing to take a distribution due to termination of employment, retirement, in-service/pre-retirement, total & permanent disability, or Plan Termination.  Please refer to your plan’s adoption agreement or SPD for more information on availability.  This form must be accompanied by the Special Tax Notice above when delivering to participants.

  PDF Version - Click Here Word Fill-In Version - Click Here

Loan Application
For use by participants electing to take a loan withdrawal.  Please refer to your plan’s adoption agreement or SPD for more information on availability.  This form must be accompanied by the plan’s Participant Loan Program when delivering to participants. 

  PDF Version - Click Here Word Fill-In Version - Click Here

Hardship Application  
For use by participants electing to take a distribution due to financial hardship.  Please refer to your plan’s adoption agreement or SPD for more information on availability.  This form must be accompanied by the Special Tax Notice above when delivering to participants.

  PDF Version - Click Here Word Fill-In Version - Click Here

Death or QDRO Form  
For use by beneficiaries or alternate payees electing to take a distribution due to death of the participant or a qualified domestic relations order.  This form must be accompanied by the Special Tax Notice above when delivering to participants.  Additional documentation may be required for processing.

  PDF Version - Click Here Word Fill-In Version - Click Here

 

 
 
PA Retirement Solutions, Inc.     |     1110 N. Mountain Road, Harrisburg, PA 17112     |      Phone Number:  717-412-4073     |      Fax Number: 717-412-4079
 
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