Retiree Forms

All forms can be electronically signed and emailed to our office. If you are sending in a paper form, please use:

Multnomah County Retiree Benefits Office
501 SE Hawthorne Blvd. Suite 320
Portland, OR 97214

Retiree Medical & Dental Plan Change Form

• Document

  Retiree Medical & Dental Change Form (300.95 KB)

Other Required Forms

• Document

  Affidavit of Marriage-Domestic Partnership (325.8 KB)

-Required if adding a spouse/domestic partner

• Document

  EFT Authorization Form for Retiree Medical Dental Plan Costs (324.54 KB)

Life Insurance Beneficiary Change Forms

• Document

  Life Insurance Beneficiary Form - $2,000 Plan (264.64 KB)
• Document

  Life Insurance Beneficiary Form - $5,000 Plan (300.72 KB)