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 445-1A: Change in Personal Information for MCPS Employees

Health benefits

Enroll in benefits

• MCPS Form 455-20: Employee Benefit Plan Enrollment
  Submit within 60 days of experiencing a qualifying life event or returning from long-term leave.

Medical forms

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

Prescription forms

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

Dental forms

• CareFirst Dental PPO Claim Form   

Vision form

• Davis Vision (provided through CareFirst) Claim Form

Flexible Spending Accounts

• MCPS Form 450-3: Flexible Spending Account Election
  Submit within 60 days of a qualifying life event or returning from long-term leave.
• Benefit Strategies Medical FSA Claim Form
• Benefit Strategies Dependent Care FSA Claim Form

Life Insurance

• MCPS Form 455-20: Employee Benefit Plan Enrollment 
  Submit within 60 days of a qualifying life event or returning from long-term leave.
• MCPS Form 450-1: Optional Employee Term Life Insurance 
  Submit within 60 days of a qualifying life event or returning from long-term leave to purchase optional employee life insurance. Submit anytime to update your beneficiaries for existing optional employee life insurance coverage.
• MCPS Form 450-2: Optional Dependent Term Life Insurance
  Submit within 60 days of a qualifying life event or returning from long-term leave to purchase optional dependent life insurance. 

Pay and Taxes

• Direct Deposit on Mingle 
  Visit Employee Self-Service (ESS) to enroll in or make a change to your direct deposit account.
• 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.
• MCEA Moving Pay Verification Form

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 440-40S: Return to Work Evaluation: SEIU Employees 
  Submit this form prior to returning to work from a health-related leave of absence.
• MCPS Form 440-40M: Return to Work Evaluation: MCEA Employees
  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 Beneficiary
  Submit to designate or change beneficiaries for your State core pension plan

Retirement 

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