Montgomery County Public Schools

Employee and Retiree Service Center → Employees → Forms

Forms

Find a form to access your benefits, make changes, and more.

Personal Information

• MCPS Form 445-1: Change in Personal Information 

Health benefits

Enroll in benefits

• MCPS Form 455-20: Employee Benefit Plan Enrollment
  Submit within 60 days of your hire date or of a qualifying event, or submit during the annual Open Enrollment period each fall.

Medical forms

• CareFirst BlueChoice Claim Form 
• CareFirst BlueChoice POS and HMO Primary Care Physician Selection Form 
• UnitedHealthcare Claim Form 
• UnitedHealthcare International Claim Form 

Prescription forms

• CVS/Caremark Claim Form 
• CVS/Caremark Mail Order Pharmacy Order Form 

Dental forms

• Aetna Dental PPO Claim Form 

Vision forms

• NVA Claim Form 

Flexible Spending Accounts

• MCPS Form 450-3: Flexible Spending Account 2012 Calendar Year Election
  Submit within 60 days of your hire date or qualifying life event to make your 2012 elections.
• Medical FSA Claim Form 
• Dependent Care FSA Claim Form 

Life Insurance

• MCPS Form 455-20: Employee Benefit Plan Enrollment
  Enrollment is automatic upon employment. Submit to disenroll, or submit to re-enroll during the annual Open Enrollment period each fall. Submit anytime to update your life insurance beneficiaries
• MCPS Form 450-1: Optional Employee Term Life Insurance 
  Submit within 60 days of employment to purchase optional employee life insurance or during annual Open Enrollment. Submit anytime to update your beneficiaries for exisiting optional employee life insurance coverage.
• MCPS Form 450-2: Optional Dependent Term Life Insurance
  Submit within 60 days of employment to purchase optional dependent life insurance or during annual Open Enrollment. 

Pay and Taxes

• Direct Deposit on Human Resources Online
  Enroll in or make a change to your direct deposit online. Receive e-mail confirmations within minutes. If you are unable to enroll online, you may instead submit MCPS Form 280-31: Direct Deposit Authorization to ERSC. Submitting a paper form increases the processing time of your enrollment or change. 
• MCPS Form W-4-MW507: Employee's Withholding Allowance Certificate 
• MCPS Form 280-3: Employee's Additional Withholding of Income Tax Agreement
  Submit this form to request that additional taxes be withheld from your pay.

Leave

• MCPS Form 430-1A: Leave Request
  Submit to your principal/supervisor for leave approval for all annual leave shorter than 5 days.
• MCPS Form 430-1: Leave Request
  Submit to your principal/supervisor for leave approval for all leaves longer than 5 days. ERSC must then receive this form at least 30 days prior to your leave start date. 
• MCPS Form 440-35: Certification of Physician or Health Care Provider
  Submit to ERSC for when taking personal illness or illness in family leave of 5 days or more.
• State Form 46: Qualified Leave of Absence Request or Notification of Military Service Entry
  Submit this form to ensure you receive credit toward retirement in your State Core Pension Plan during an approved leave.
• MCPS Form 440-40: Return to Work Evaluation
  Submit this form prior to returning to work from a health-related leave of absence.

Pension Plans

MCPS Core Plan

• MCPS Form 455-3: Membership Information Montgomery County Public Schools Employee Pension System
  All new employees must submit to enroll in the MCPS Core and Supplemental pension plans
• MCPS Form 455-5: Designation of Beneficiary(ies)
  Submit to designate or change beneficiaries for your MCPS core and/or supplemental pension plans

State Core Plan

• State Form 1: Application for Membership
  Submit if you are eligible for membership in the State core pension plan
• State Form 4: Designation of BeneficiarySubmit to designate or change beneficiaries for your State core pension plan

 Retirement

Changes to your 403(b)/457(b) Plan

• Forms index 

Obtaining Additional Service

• ERSC Form 421: Request to Purchase Service
  Submit this form to initiate the process of purchasing additional credited service towards your retirement.
•  MCPS Form 455-18: Statement of Military Service
  Submit this form to request service  in your MCPS Core and/or Supplement Pension Plan for time spent in the military.
• State Form 46: Qualified Leave of Absence Request or Notification of Military Service Entry
  Submit this form to request service in your State Core Pension Plan for time spent in the military.
   

Request for Estimate

• MCPS Core and Supplemental Benefit Plan  
• State Core Benefit Plan 

Retirement Application

• State Core Plan members 
• Non-State Core Plan members