Fillable Printable Form Member Information
Fillable Printable Form Member Information
Form Member Information
Member Information Form
This form is for new and returning employees
hired into retirement-eligible positions for PERS,
SERS or TRS. Submit this form to your employer
within 90 days of your hire date.
Give completed form to your employer.
Need help? Contact DRS.
800.547.6657 or 360.664.7000
TTY: 711 ꔷ
www.drs.wa.gov
Member Status and System
Member status
c New Member
Choosing Plan 2: Complete Sections 1, 2 and 3
Choosing Plan 3: Complete Sections 1, 2, 3 and 4
c Returning Plan 1 or Plan 2 Member
Complete Section 1 only
c Returning Plan 3 Member
Complete Sections 1, 3 and 4
System
c TRS
Teachers’ Retirement System
c SERS
School Employees’ Retirement System
c PERS
Public Employees’ Retirement System
Section 2: Retirement Plan Selection (new members)
Choose your plan. Your decision is permanent. Note: you will be assigned to Plan 3 if your employer has not
received your plan selection within 90 calendar days of your date of hire.
c Plan 2
c Plan 3 — Also complete Section 4 on the back
Section 3: Signature Required (new and returning members)
Sign and date this form on the day you submit it to your employer.
New member: I have chosen the retirement plan marked in Section 2. I understand that my retirement
plan selection is permanent. If I selected Plan 3, I have also completed Section 4 on the back of this form.
Returning Plan 3 member: I have completed Section 4 on the back of this form. I also understand that
returning Plan 3 members who do not select a contribution rate within 90 days will be assigned the
current default rate of 5%.
Signature Date
Section 1: Personal Information
Name (last, rst, middle) Social Security Number
Mailing Address City State ZIP
Birthdate (mm/dd/yyyy) Gender (optional)
c Male c Female
Phone Number
Email Address
Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your
Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109.
DRS MS 133 7/17
Clear Form
Return the completed form to your employer.
Section 5: To Be Completed by Employer
Employer Name and Mailing Address
Reporting Group
Employers: Mail the original of this form
to DRS only if Section 2 was required.
Department of Retirement Systems; PO
Box 48380; Olympia, WA 98504-8380
Section 4: Plan 3 Contribution Rate and Investment Program Selection
Choose an income contribution rate. If you do not choose an option, your default will be Option A. Once
established by selection or default, you may change your rate option only with a change of employer or
through the purchase of optional service credit from work as a substitute teacher.
Age
Member
Contribution Rate
c Option A
All ages 5.0%
c Option B
Up to age 35
Ages 35 to 44
Ages 45 and older
5.0%
6.0%
7.5%
c Option C
Up to age 35
Ages 35 to 44
Ages 45 and older
6.0%
7.5%
8.5%
c Option D
All ages 7.0%
c Option E
All ages 10.0%
c Option F
All ages 15.0%
Choose an investment program. If you do not choose an investment program, you will be defaulted
into the Self-Directed Investment Program and all of your contributions will be invested in the Retirement
Strategy Fund that assumes you’ll retire at age 65. You can change your investment program at any time.
c Washington State Investment Board (WSIB) Investment Program
c Self-Directed Investment Program
You must choose how your contributions will be invested. You may do so by phone at 888-327-5596
or online at
drs.wa.gov/login
.
If you do not choose your investment allocations, your contributions will
be invested in the Retirement Strategy Fund that assumes you’ll retire at age 65.
For more information about these investment programs, contact the DRS record keeper Empower
Retirement at 888-327-5596.
