Most Board of Pensions forms are available here. However, several are not posted, so if you cannot find the form you require, please contact Member Services. 

The forms are available in PDF (Portable Document Format) and are best viewed with the latest (free) version of Adobe Acrobat Reader. Forms submitted to the Board of Pensions must be clear and legible, and on good quality 8.5" by 11" white paper.

These forms can be printed, completed, and mailed to:

The Board of Pensions of the Presbyterian Church (U.S.A.)
2000 Market Street
Philadelphia, PA 19103-3298

Traditional Program  |   Affiliated Benefits Program  |  Change of Address/Contact Information  |  Assistance and Retirement Housing  |  Death Benefits  |  Disability Benefits  |  Electronic Funds Transfer  |  Flexible Spending Account  |  Giving Opportunities  |  HIPAA/Privacy  |  Medical/Healthcare  |  Supplemental Death Benefits  |  Pension Plan  |  Retirement Savings Plan  |  Optional Dental Program

Traditional Program

• Benefits Plan Membership Application (enr-001) 
  Use this form to enroll in the Traditional Benefits Plan.
• Benefits Plan Membership Application, Seminary Student (enr-003) 
  Use this form to enroll in the Benefits Plan as a Seminary Student.
• Optional Coverages Termination (enr-006) 
  Use this form to terminate optional benefits coverage.
• Dependent Change (enr-101) 
  Use this form to add/update dependent information in the Traditional Plan. Or visit Benefits Connect to complete the process quickly and securely online.
• Transitional Participation Coverage Enrollment (enr-102)
  Use this form to continue participation in the Traditional Benefits Plan under the unemployment status.
• Post-Retirement Service Registration (enr-104) 
  Use this form to report or terminate a Post-Retirement service.
• Service Change (enr-110) 
  Use this form to report a service change under the Traditional Plan.
• Change of Salary (enr-111) 
  Use this form to report a salary change under the Traditional Plan.
  Or, if you are a treasurer or business administrator, visit Benefits Connect to complete the process quickly and securely online.
• 14-09 Couple Verification (enr-206) 
  Use this form to verify 14-09 couple eligibility. (For churches)
• Service Termination (enr-301) 
  Use this form to report service terminations or withdrawals from the Benefits Plan.
• Waiver of Coverage for Specialized Ministries (enr-901) 
  Use this form if you are waiving required Traditional benefits while participating in a validated ministry.

Affiliated Benefits Program

• Affiliated Benefits Program - Membership Application (enr-002) 
  Use this form to enroll in the Affiliated Benefits Plan.
• Affiliated Benefits Program - Medical Continuation Program (enr-004) 
  Use this form to participate in Medical Continuation coverage for the Affiliated Benefits Plan.
• Affiliated Benefits Program - Employer Agreement (enr-005) 
  Use this form to enroll your organization into the Affiliated Benefits Plan or to declare/change your organization's Plan enrollment guidelines. (For employers)
• Affiliated Benefits Program - Employer Enrollment Checklist (enr-007) 
  Use this worksheet as an Affiliated Benefits Plan enrollment checklist. (For employers)
• Affiliated Benefits Program - Enrollment Timeline (enr-008) 
  Use this worksheet to determine the Affiliated Benefits Plan suggested timeline for enrollment.
• Affiliated Benefits Program - Termination/Service/Salary Change (enr-103) 
  Use this form to report an Affiliated Benefits Plan member's termination, service, or salary changes.
• Affiliated Benefits Program Dependent Change (enr-107) 
  Use this form to add/update dependent information in the Affiliated Benefits Plan.

Change of Address/Contact Information

• Address and Contact Information Change (enr-106)
  Use this form to report a change to your address, email, or telephone number. Or visit Benefits Connect to complete the process quickly and securely online.
• Church/Employing Organization Address and Contact Information Change (enr-112)
  Use this form to report a change or correction to a church or employing organization's address, email address, phone number, or billing contact information.

Assistance and Retirement Housing

• Financial Disclosure Statement for Assistance - Update Information (arh-001) 
  Use this form to apply for additional assistance funds.
• Financial Disclosure Statement for Assistance (arh-002) 
  Use this form to apply for financial assistance.
• Retirement Housing Application (arh-003) 
  Use this form to apply for placement for retirement housing.
• Seminary Debt Assistance Program Application (arh-004) 
  Use this form to apply for the Seminary Debt Assistance Program.
• Middle Governing Body Grant - Participant's Evaluation (arh-005) 
  Use this form to submit an evaluation of the training program for the Middle Governing Body Grant.
• Middle Governing Body Grant Program Evaluation (arh-007)
  Use this form to submit an evaluation of a program established through a Middle Governing Body Grant (to be completed by the middle governing body).
• Middle Governing Body Grant Application (arh-605) 
  Use this form to apply for a Middle Governing Body Grant.
• Transition-to-College Assistance Grant Application for 2010-2011 academic year (arh-606) 
  Use this form to apply for a Transition-to-College Assistance Grant.
• Retiree Pension Withholding Authorization (arh-900) 
  Use this form to request a direct deduction of rent from pension check for Board housing.
• Shared Grant Application 
  This form should be available to pastors through their presbytery and to lay workers through their employing organization. (Presbyteries and employing organizations that require the form can contact the Assistance Team at the Board.)

Death Benefits

• Death Benefits Beneficiary Designation (dbn-001) 
  Use this form to designate Salary Continuation Benefit beneficiaries.
• Death Benefits Claim (dbn-600) 
  Use this form to apply for payment of death benefits.
• Student Application for Education Benefits (dbn-601) 
  Use this form to apply for Education Benefits.
• Verification of Enrollment - New Student (dbn-602) 
  Use this form to verify new student enrollment when applying for Education Benefits.
• Verification of Enrollment - Continuing Student (dbn-603) 
  Use this form to verify continuous student enrollment when applying for Education Benefits.
• Taxation of Death Benefit Dues Calculator
  Use this online calculator to quickly determine the imputed income that must be reported on W-2 forms for death benefits through the Benefits Plan. (This calculator replaces the Taxation of Death Benefits Worksheet to ensure accurate results.)

Disability Benefits

• Member Disability Plan Benefit Application 
  Use this form to apply for disability benefits.

Electronic Funds Transfer

• Authorization for Direct Deposit (eft-001) 
  Use this form to add/change Electronic Fund Transfer information for pensioners. Or visit Benefits Connect to complete the process quickly and securely online.

Flexible Spending Account (FSA)

• Sample Guide for Employers Considering Health FSAs (fsa-001) 
  Use this form for general information about Flexible Spending Account benefits.
• Sample Session Resolution (fsa-002) 
  Use this form to agree to terms of a Flexible Spending Account. (For employers)
• Sample Health Flexible Spending Plan Employee Summary  (fsa-003) 
  Use this form to estimate the amount set aside for a Flexible Spending Account.
• Sample Health FSA Enrollment (fsa-004) 
  Use this form to enroll in a Flexible Spending Account.
• Sample Health FSA Worksheet (fsa-005) 
  Use this form to calculate Flexible Spending Account health expenses.
• Sample Reimbursement Claim Form for Health FSA (fsa-007) 
  Use this form to apply for Flexible Spending Account reimbursement for eligible medical expenses.
• Sample Health Flexible Spending Plan Document
  Employers can use this sample documentation to help prepare and adopt its own plan document with the advice of its own legal and tax counsel.

Giving Opportunities

• Assistance Program - Donation Form (fdd-100)
  Use this form if you want to make a monetary gift to the Assistance Program of the Board of Pensions.

HIPAA/Privacy

• Authorization to Release Medical Plan Information (hpa-001) 
  Use this form to authorize the Board to release Protected Health Information to others.
• Authorization to Release Medical Plan Information -Korean (hpa-001_korean)
  Use this form to authorize the Board to release Protected Health Information to others.
• Authorization to Release Medical Plan Information—Spanish (hpa-001_spanish)
  Use this form to authorize the Board to release Protected Health Information to others. 
• Authorization for Use or Disclosure of Protected Health Information (hpa-002) 
  Use this form to authorize the Board to receive Protected Health Information from others.
• Authorization for Use or Disclosure of Protected Health Information - Korean (hpa-002_korean) 
  Use this form to authorize the Board to receive Protected Health Information from others.
• Authorization for Use or Disclosure of Protected Health Information - Spanish (hpa-002_spanish) 
  Use this form to authorize the Board to receive Protected Health Information from others.
• Medical Plans - Request for Access to PHI (hpa-003)
  Use this form to request your Protected Health Information from the medical plans.
• Medical Plans - Request to Amend PHI (hpa-004) 
  Use this form to request amendments to your Protected Health Information or designated record set from the medical plans.
• Medical Plans - Request for Accounting Disclosures (hpa-005) 
  Use this form to request an accounting of disclosures.
• Member or Dependent Authorization to Use and Disclose Personal Employment and Financial Information (hpa-006) 
  Use this form to authorize the Board to disclose personal/employment/finance information.
• Personal Representative Request (enr-903) 
  Use this form to authorize the Board to provide information to your designated legal representative. 
• Designation of Personal Representative (enr-904) 
  Use this form to authorize the Board to provide information to your designated legal representative. 

Medical/Healthcare

• Dependent Coverage Waiver and Re-enrollment (enr-009)
  Use this form to waive coverage or re-enroll your spouse and/or dependent(s) in the Medical Plan.
• The Benefits Plan of the Presbyterian Church (U.S.A.) Medicare Secondary Payer – Small Employer Exception Election Employer Certification Form (med-209)
  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. Instructions for completing the form are found on the reverse side of the form.
• Worksheet for Full-time Equivalent Salary Basis for Healthcare Dues (enr-108) 
  Use this form to estimate part-time workers' full-time equivalent salary for healthcare dues.
• Medical Continuation Subscription or Waiver (med-100) 
  Use this form to participate in the Medical Continuation Program or to waive coverage.
• Medicare Supplement Subscription, Waiver, or Withdrawal (med-200) 
  Use this form to participate in the Medicare Supplement Program or to waive Medicare Supplement coverage.
• Withdrawal to Participate in TRICARE for Life (med-208) 
  Use this form to terminate retiree medical coverage to subscribe to TRICARE.
• Clergy Colleague Group (med-213) 
  Use this form to obtain funding for a Clergy Colleague Group.
• Change of Medical Plan Participation for Mission Personnel (med-214) 
  Use this form to change Medical when transitioning to and from overseas duty.  (For missionaries)
• Seminary Student Enrollment Checklist  
  Use this checklist to ensure that all items required to enroll as a seminary student are completed and submitted. 

Supplemental Death Benefits

• Supplemental Death Benefits Application (odb-000) 
  Use this form if you are interested in applying for additional death benefits.
• Supplemental Death Benefit Medical Statement (Member) (odb-001) 
  Use this medical statement for Supplemental Death Benefits. (For members)
• Supplemental Death Benefit Medical Statement – Spouse (odb-001a) 
  Use this medical statement for Supplemental Death Benefits. (For spouses)
• Supplemental Death Benefit Beneficiary Designation (odb-002) 
  Use this form to report Supplemental Death Benefits beneficiaries. (For active members)
• Application for Retiree Supplemental Death Benefits (odb-003) 
  Use this form to report Supplemental Death Benefits beneficiaries. (For retirees)
• Tobacco Use Declaration (odb-801) 
  Use this form to declare either tobacco use or tobacco free. (For members or spouses)
• Taxation of Death Benefits Worksheet (dbn-604)
  Use this worksheet to calculate imputed income that must be reported on W-2 forms for death benefits coverage through the Benefits Plan. Or use the Taxation of Death Benefit Dues Calculator to quickly determine this amount online.

Pension Plan

• Tax Withholding Election (pen-005) 
  Use this form to have taxes withheld from a pension, survivor, or disability check.
• Election of Pension Payment for Former EAF Employees (pen-006) 
  Use this form if you are retiring and a former member of the Employee Annuity Fund.
• Retirement Pension Application - Former Spouse (pen-007)
  Use this form if you are applying for pension benefits as an ex-spouse.
• Social Security Leveling Option Agreement (pen-201) 
  Use this form to obtain Social Security Leveling for retirement.
• Application for Mandatory Cashout Exception (pen-205) 
  Use this form if you are applying for the mandatory Cash Out exception.
• Study of Retired Members (pen-206) 
  Use this form to help the Board create a summary of retirement income and forecast the needs addressed by the Assistance Program.
• Authorization to Release Pension Information (pen-902) 
  Use this form to authorize someone to receive your personal pension information.

Retirement Savings Plan

• The Retirement Savings Plan Enrollment Kit  
  Use this booklet for forms and instructions for joining The Retirement Savings Plan.
• Retirement Savings Plan Salary Deferral Agreement (ors-001)
  Use this form if you are a new participant, changing your employer, suspending contributions, or changing your contribution amount.
• Fidelity Beneficiary Designation 
  Use this form to report/change retirement savings plan beneficiaries.
• Retirement Savings Plan Of the Presbyterian Church (U.S.A.) Adoption Agreement (ors-006)
  Use this form when enrolling your organization as an adopting employer of the Retirement Savings Plan for your employees. (For employers)
• Initial Contribution Remittance Form
  Use this form for your initial contribution to your 403(b)(9) Retirement Savings Plan of the Presbyterian Church (U.S.A.).
• Fidelity Investments Enrollment Form
  Use this form to enroll for the 403(b)(9) Retirement Savings Plan of the Presbyterian Church (U.S.A.)

Optional Dental Program

• PPO Enrollment Form (odn-005)
  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.)
• Passive PPO Enrollment Form (odn-004)
  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.)
• Dual Option (PPO and DMO) Enrollment Form (odn-003)
  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.)
• Texas Dual Option (Passive PPO and DMO) and Texas Passive PPO Enrollment Form (odn-006)
  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.)