TESRS

Texas Emergency Services Retirement System

Forms & Publications

Form 502 - New Member Form - this form is completed by each volunteer who is a member of the department.


Form 503 – Member Information Update – this form is used by active members (not retirees) if they need to update their contact information and/or beneficiaries.


Form 504 - Termination Record - this form is used by departments to terminate members.


Form SCA - 2016 Service Credit Approval - this form is used by local boards to award service credit for 2016 prior to submission of the 2016 Annual Report.


Form AVAC – Address Change – this form is used for active and terminated/vested members to change their mailing address.


Form PAC – Payee Address change – this form is used by retirees and spouses who want to change their personal information and banking information. 


Service Retirement Application
– this form is the application that members fill out when they want to retire.  This form must accompany the IRS W-4P tax form (see next form)

IRS W-4P – this is the 2017 IRS tax form completed by retirees and surviving spouse.


Direct Deposit Authorization – this form is used by retirees and spouses who wish to have their checks direct deposited or to change your existing direct deposit information. 


Form 411-S1 – Survivor’s Annuity Plan – this is the form used by surviving spouse to apply for the decedent’s benefits.  This form must be accompanied by a copy of the death certificate. 


Form TDIS – APP – Temporary Disability Form – this form is used to apply for temporary disability benefits.


Form 200-A – Local Board Authorization Form - this form is used by the Local Board to authorize those listed to have on-line access to the TESRS System.


Form 200-B – Contribution Changes - this form is used by the department and Local Board to authorize a change in the contribution rate.  Any changes to the rate must be pre approved by the governing entity.


Form 200-C – Retroactive Supplemental Contribution – this form is used to make a lump sum retroactive contribution and have it applied to the time period indicated.  


Form 200-D Error Correction – this form is used by the local board to correct qualified service credit for its members.


Summary of Benefits Flyer - Informational flyer that lists all the benefits of the TESRS system, describes contributions, and provides contact information of our agency.


Meeting Notice Template – this form is an example of a Local Board meeting notice to be publicly posted at least 72 hours in advance of the meeting date and time.  

 

Compliance Checklist – this is an informational form.  It is used by departments and local boards as a self-assessment tool to check compliance with TESRS statutes and rules. 


Physical Fitness Form – this is an optional form; it can be used by physicians and departments to document the volunteer's physical fitness.  All physical fitness documentation is for department use/records only and should not be sent in to TESRS.


Department ACH/Set up/Change – this form is used by governing entities to either set up their account or make changes to their account for contribution payments.

Model QDRO Form - Qualified Domestic Relations Order - This template is specific to TESRS benefits and must be used as the QDRO to assign any portion of TESRS benefits.

Texas Administrative Code -  Rules for the Texas Emergency Services Retirement System pension program are codified in the Texas Administrative Code.

TESRS Statutes and Administrative Rules -  Texas Administrative Statutes and Administrative Rules

Form 601 - Local Participating Department Roster - this form is used to list all personnel who are current volunteers or auxiliary members for a department including those who are and who are not members of the Pension System.

Form 601 Excel - Local Participating Department Roster - Same as above, but in an Excel spreadsheet.

Form 601 Instructions - Instructions for Local Participating Department Roster - this document provides instructions for completing Form 601

Form 602 - Local Board Membership - this form is used to provide information about the six members of the Local Board.

Form 602 Instructions - Instructions for Local Board Membership - this document provides instructions for completing Form 602

Form 603 - Governing Entity Contact Information - this form is used to provide information about the authorized signatory and financial personnel of the governing entity.

Form 603 Instructions - Instructions for Governing Entity Contact Information - this document provides instructions for completing Form 603.