Texas Emergency Services Retirement System

Forms & Publications

Local Board Guide - An overview of how to structure your Local Board and meet requirements for TESRS.  

Confidentiality Agreement - Authorized users must read and certify this agreement in order to gain access to the TESRS online database.

TESRS Online Training Manual  - An overview of TESRS Online (TOL) database functions for authorized users.

Membership Reconciliation Report Procedural Document - An overview of how authorized users complete an MRR in TOL.

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 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 Instructions

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)

TESRS Withholding Form -  Retirees and surviving spouses may use this form to replace the IRS W-4P.

IRS W-4P – this is the link to the 2018 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 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 Correction of Error – 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 FAQ – this provides an overview of frequently asked questions about the requirements for physical certifications in 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.

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.