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Active Member Forms
$5,000 Beneficiary Designation 
Allows you to list your beneficiary(ies) for the $5,000 death benefit
BackDROP Distribution Form 
Change of Personal Information 
Designation of Agent 
Allows you to choose an Agent who can make MPERS benefit decisions if you become disabled
Direct Deposit Application 
Disability Packet 
To apply for disability through The Standard.
MoDOT Cancer Insurance Deduction Authorization/Cancellation 
Cancer insurance through Central United Insurance Company for MoDOT employees only.
Notice of Intent to Retire 
Use this form to apply for retirement. Step 1 of the 2 Step Retirement Process
Power of Attorney Authentication Certificate 
Request for DBO Estimate 
Survivor Application 
This form must be completed by the survivor and accompanied by the required documentation before the survivor can begin receiving benefit payments after retiree's death
Tax Free Rollover Certification 
Transfer of Creditable Service 
Verification of Transfer/Purchase Credit 
W4 P Substitute 
Use this form to make your Federal and Missouri State tax withholding elections

Office Location: 1913 William St., Jefferson City, MO 65109 | Mailing Address: Post Office Box 1930, Jefferson City, MO 65102
Telephone Number: (573) 298-6080 Toll Free: 1-800-270-1271 Fax: (573) 526-5895 Email: mpers@modot.mo.gov