DRS MS 102 (R 5/2012)
ENROLLMENT FORM
P.O. Box 48380 Olympia, WA 98504-8380 w www.drs.wa.gov
Toll Free: 1.800.547.6657 w Olympia Area: 360.664.7000 w TTY: 360.586.5450
INSTRUCTIONS
Complete this form if you are a new member of or a returning member to a LEOFF or WSPRS eligible position. All plan
members must complete a “Beneciary Designation” form. Return completed form to your employer.
EMPLOYER DATA - To be completed by employer and returned to DRS
Reporting Group First Date of Employee Eligibility
M M D D Y Y Y Y
Retirement System (check one)
c WSPRS c LEOFF
Plan
c Plan 1 c Plan 2
Employee Position Title
*DRSMS102*
Print or type employer name and mailing address below: I certify all of the information entered on this form is true and complete
and the employee’s Social Security number has been veried.
Print Name
Personnel or Payroll Representative Title Phone Number
Signature
PERSONAL DATA - To be completed by member and returned to employer
Name (Last, First, Middle) Maiden Name Social Security Number
Mailing Address City State ZIP
Phone Alternate Phone Email Address
I certify all of the information I have entered on this form is true and complete.
Employee Signature Date
Department of Retirement Systems (DRS) requires that you provide your Social Security number for this form.
• DRS will use your Social Security number as a reference number and to ensure that any funds disbursed under
your account are correctly reported to the IRS.
• DRS will not disclose your Social Security number unless required by law.
• Internal Revenue Code Sections 6041(a) and 6109 allow DRS to request your Social Security number.
