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Forms

    
      




Assistance and Retirement Housing
Number TITLE AND DESCRIPTION
arh-001Financial Disclosure Statement for Assistance (Update Information)

Use this form to apply for additional assistance funds.

arh-002Personal Financial Disclosure Statement for Assistance

Use this form to apply for assistance funds.

arh-004Minister Educational Debt Assistance Application

Use this form to apply for the Minister Educational Debt Assistance Program.

arh-900Retiree Pension Witholding Authorization

Use this form to request a direct deduction from your pension check for rent for Board housing.

arh-006Sabbath Sabbatical Support Grant Program Application

Use this form to apply for a Sabbath Sabbatical Support Grant.

arh-606Transition-to-College Assistance Grant Application

Use this form to apply for a Transition-to-College Assistance Grant.



Benefits Plan
Number TITLE AND DESCRIPTION
enr-001Benefits Plan Membership Application

Enroll an employee in the Benefits Plan online through Benefits Connect.

enr-20614-09 Couple Verification

Use this form to verify 14-09 couple eligibility. (For churches)

enr-104Post-Retirement Service Registration

Use this form to report a post-retirement service.

enr-301Termination of Plan Benefits

Report a termination of employment online through Benefits Connect.

enr-101Life Event Change (Retirees, Survivors, & Inactive Plan Members)

Active plan members report life events (such as getting married or the birth of a child) online through Benefits Connect. Retirees, survivors, and inactive plan members: Use this form to report a life event change.

enr-116Change in Employment Status or Benefit Group

Use this form to report a change in benefit group or scheduled hours for employees who are currently participating in the plan.

enr-003Seminary Student Benefits Plan Membership Application

Use this form to enroll in the Benefits Plan as a seminary student.

enr-110Service Change

Report changes in PC(USA) service online through Benefits Connect.

enr-102Transitional Participation Coverage Enrollment

Use this form to continue participation in Pastor's Participation under the unemployment status.

ENR-115Validated Ministry Registration

Use this form to report a new validated ministry employer.



Board University
Number TITLE AND DESCRIPTION
edu-001Calculating Your Net Worth



Change of Address / Contact Information
Number TITLE AND DESCRIPTION
enr-106Address and Contact Information Change

Change your contact information online through Benefits Connect.



Death Benefits
Number TITLE AND DESCRIPTION
dbn-001Beneficiary Designation

Members with Death Benefits coverage can add or change beneficiaries online through Benefits Connect.

dbn-600Death Benefits Claim

Use this form to apply for payment of death benefits.

dbn-601Student's Application for Education Benefit

Use this form to apply for educational benefits.



Dental Plan
Number TITLE AND DESCRIPTION
odn-003Dental Benefits - Dual Option Enrollment

Use this form to enroll in the Dental Program. (Please use the Dental Benefit Rate Checker to determine which option is available in your area.)

odn-004Dental Benefits - Passive PPO Option Enrollment

Use this form to enroll in the Dental Program. (Please use the Dental Benefit Rate Checker to determine which option is available in your area.)

odn-005Dental Benefits - PPO Option Enrollment

Use this form to enroll in the Dental Program. (Please use the Dental Benefit Rate Checker to determine which option is available in your area.)



Disability Benefits
Number TITLE AND DESCRIPTION
dsb-002Disability Information Packet

Use this form to apply for disability benefits.



Electronic Funds Transfer
Number TITLE AND DESCRIPTION
eft-001Authorization for Direct Deposit

Use this form to add/change Electronic Fund Transfer information for pensioners.



Giving Opportunities
Number TITLE AND DESCRIPTION
fdd-100Assistance Program Gift and Donation Form

Use this form if you want to make a monetary gift to the Assistance Program of the Board of Pensions or securely give online.



HIPAA/Privacy
Number TITLE AND DESCRIPTION
enr-904Designation of Personal Representative

Use this form to authorize the Board to provide information to your designated legal representative.

hpa-001Authorization to Release Medical Plan Information

Use this form to authorize the Board to release protected health information to others.

hpa-001Authorization to Release Medical Plan Information (Korean)

Use this form to authorize the Board to release protected health information to others.

hpa-001Authorization to Release Medical Plan Information (Spanish)

Use this form to authorize the Board to release protected health information to others.

hpa-002Authorization for Use or Disclosure of Protected Health Information

Use this form to authorize the Board to receive protected health information from others.

hpa-002Authorization for Use or Disclosure of Protected Health Information (Korean)

Use this form to authorize the Board to receive protected health information from others.

hpa-002Authorization for Use or Disclosure of Protected Health Information (Spanish)

Use this form to authorize the Board to receive protected health information from others.

hpa-006Member or Dependent Authorization to Use and Disclose Personal Employment and Financial Information

Use this form to authorize the Board to disclose personal/employment/finance information.

hpa-005Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request for Accounting of Disclosures

Use this form to request an accounting of disclosures.

hpa-003Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request for Access to PHI

Use this form to request your protected health information from the medical plans.

hpa-004Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request to Amend PHI

Use this form to request amendments to your protected health information or designated record set from the medical plans.



Medical/Healthcare
Number TITLE AND DESCRIPTION
med-214Change of Medical Plan Participation for Mission Personnel

Use this form to change Medical Plan participation when transitioning to and from overseas duty. (For missionaries)

VSP Member Reimbursement

Small Employer Exception (SEE) Package

This form should be completed by the employer of any active employee participating in the Medical Plan on or before the date that the employee turns age 65.

Active Home Delivery Form

med-207Proof of Eligible Service for Retiree Medical Coverage



Other
Number TITLE AND DESCRIPTION
HRS-001Application for Employment



Pension Plan
Number TITLE AND DESCRIPTION
pen-007Retirement Pension Application - Former Spouse

Use this form if you are applying for pension benefits as a former spouse.

pen-201The Social Security Leveling Option Agreement

Use this form to obtain Social Security Leveling for retirement.

pen-205Application for Mandatory Cashout Exception

Use this form if you are applying for the mandatory cashout exception.

pen-206Study of Retired Members

Use this form to help the Board create a summary of retirement income and forecast the needs addressed by the Assistance Program.

pen-902Authorization to Release Pension Information

Use this form to authorize someone to receive your personal pension information.

pen-005Tax Withholding Election

Use this form to have taxes withheld from a pension, survivor, or disability check.



Retirement Savings Plan
Number TITLE AND DESCRIPTION
Retirement Savings Plan of the Presbyterian Church (U.S.A.) (Fidelity Enrollment Form)

Use this form to enroll for the 403(b)(9) Retirement Savings Plan of the Presbyterian Church (U.S.A.).

ors-001Retirement Savings Plan Salary Deferral Agreement

Use this form if you are a new participant, changing your employer, suspending contributions, or changing your contribution amount.

ors-001Plan de Ahorro para la JubilaciĆ³n Acuerdo de Aplazamiento Salarial

Use this form if you are a new participant, changing your employer, suspending contributions, or changing your contribution amount.

Retirement Savings 403(b) Beneficiary Designation Form - Fidelity Investments

Use this form to report/change Retirement Savings Plan beneficiaries.

rsp-200Non-QCCO Discrimination Testing for the RSP

Use this form if you are a non-QCCO determining whether or not discrimination testing is required. (For employers)

Initial Contribution Remittance Form for the Retirement Savings Plan of the Presbyterian Church (U.S.A.)

Use this form for your initial contribution to your 403(b)(9) Retirement Savings Plan of the Presbyterian Church (U.S.A.).

Initial Contribution Remittance Form for the Retirement Savings Plan of the Presbyterian Church (U.S.A.) (Spanish)

Use this form for your initial contribution to your 403(b)(9) Retirement Savings Plan of the Presbyterian Church (U.S.A.).



Supplemental Death Benefits
Number TITLE AND DESCRIPTION
odb-000Supplemental Death Benefits Application

Use this form if you are interested in applying for additional death benefits.

odb-001Supplemental Death Benefits Health Statement (Member)

Use this health statement for supplemental death benefits. (For members)

odb-001aSupplemental Death Benefits Health Statement (Spouse)

Use this health statement for supplemental death benefits. (For spouse)

odb-801Tobacco Use Declaration

Use this form to declare whether or not you use tobacco. (For members and spouses)