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MoDOT & Patrol Employees'
Retirement System
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Terminated/Vested Forms
$5,000 Beneficiary Designation 
Allows you to list your beneficiary(ies) for the $5,000 death benefit
$5,000 Beneficiary Designation 
Allows you to list your beneficiary(ies) for the $5,000 death benefit
Change of Personal Information 
Direct Deposit Application 
Divorce Brochure 
Notification of Intent to Retire 
Use this form to apply for retirement. Step 1 of the 2 Step Retirement Process
Retirement Application 
Service Purchase/Rollover Certification Form 
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
W4 P Substitute 
Use this form to make your Federal and Missouri State tax withholding elections
Mailing Address: PO Box 1930, Jefferson City, MO 65102-1930 • Office Location: 1913 William St., Jefferson City, MO 65109
Phone Number: (573) 298-6080 • Toll Free: (800) 270-1271 • Fax: (573) 526-5895 • Email: mpers@modot.mo.gov