Instructions For Tier One Tier Two And Iap Account No Award To Former Spouse Page 2
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211410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Phone – 503-598-7377, toll free – 888-320-7377
Fax – 503-598-0561, website –
Tier One/Tier Two Program and IAP Account (Non-Retired Member)
No Award to Former Spouse
This form is strictly for members with Tier One/Tier Two and IAP accounts who have been awarded their accounts in entirety.
Section A: Member and former spouse information
(Type or print clearly in dark ink.)
Member’s full name
Please provide one of the following for the member:
PERS number ________________________________________
Social Security number_________________________________
Former spouse’s full name
Date of birth ____________________________________________
Section B: Non-retired member benefi ts awarded to member
Check the appropriate box(es) below, attach this form as an exhibit to the court order, and submit it to the
courts. No other PERS forms are required.
The member is awarded his/her Tier One/Tier Two current member account and future retirement
benefi ts.
The member is awarded his/her IAP current member account and future retirement benefi ts.
Print Form
Clear Fields
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling 503-598-7377, toll free 888-320-7377,
or TTY 503-603-7766.
Form #459-564a (6/13/2013) SL3 IIM Code: 9981
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