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
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.
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.