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Forms

    
      




Affiliated Benefits Program
Number TITLE AND DESCRIPTION
ENR-118Affiliated Benefits Program Change in Employment Status

Use this form to report a change in employment status, such as hours, employment classification, and Benefits Plan participation under the Affiliated Benefits Program.

enr-008Affiliated Benefits Program Enrollment Timeline

Use this worksheet to determine the suggested timeline for enrollment in the Affiliated Benefits Program.

ENR-119 Affiliated Benefits Program Service Change

Use this form to report a new service under the Affiliated Benefits Program.

enr-005Affiliated Benefits Program Employer Agreement

Use this form to enroll your organization into the Affiliated Benefits Program or to declare/change your organization's plan enrollment guidelines. (For employers)

enr-007Affiliated Benefits Program Employer Enrollment Checklist

Use this worksheet as an Affiliated Benefits Program enrollment checklist. (For employers)



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

Use this form to enroll an employee in the Benefits Plan.

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

Use this form to report service terminations or withdrawals from the Benefits Plan.

enr-101Life Event Change

Use this form to report a life event change, such as getting married or the birth of a child.

enr-116Change in Employment Status

Use this form to report a change in employment status, such as hours or employment classification.

enr-003Seminary Student Benefits Plan Membership Application

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

enr-110Service Change

Use this form to report a new service under the Traditional Program.

enr-102Transitional Participation Coverage Enrollment

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

ENR-115Specialized Ministry Registration

Use this form to report a new service to a specialized ministry.



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

Use this form to report a change to your address, email, or telephone number.



Death Benefits
Number TITLE AND DESCRIPTION
dbn-001Beneficiary Designation

Use this form to designate Salary Continuation Benefit and/or Supplemental Death Benefit beneficiaries.

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.



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



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

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

odn-004Optional Dental Benefits - Passive PPO Option Enrollment

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

odn-005Optional Dental Benefits - PPO Option Enrollment

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



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 Jubilación Acuerdo de Aplazamiento Salarial

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

ors-006Retirement Savings Plan of the Presbyterian Church (U.S.A.) Adoption Agreement

Use this form when enrolling your organization as an adopting employer of the Retirement Savings Plan for your employees. (For employers)

ors-006Plan de Ahorro para la Jubilación Acuerdo de Adopción

Use this form when enrolling your organization as an adopting employer of the Retirement Savings Plan for your employees. (For employers)

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)