TESRS

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Forms & Publications

On this page you will find links to all of our forms, including instructions on how to fill them out
as well as links to our most current Statutes and Rules

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.