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MoDOT & Patrol Employees'
Retirement System
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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 Brochure 
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
Designation of Beneficiary for Employee Contributions 
Direct Deposit Application 
Disability Packet 
To apply for disability through The Standard.
Divorce Brochure 
Leaving State Employment 
MoDOT Cancer Insurance Deduction Authorization/Cancellation 
Cancer insurance through Central United Insurance Company for MoDOT employees only.
Notification 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 
Special Tax Notice 
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 
To be used for verification of prior full-time, non-federal public employment worked in the State of Missouri.
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