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HART Forms

Form Name & Number Description
Enrollment Form #110 Enrollment Form #110

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Change of Address Form #120 Change of Address Form #120
Age 55 or Older Provision Form #130 Request For Partial Payments Under the “Age 55 Or Older Provision” Form #130
Change of Beneficiary Form #140 Change of Beneficiary Form #140
Request for Benefit Payment Form Package #150 Request for Benefit Payment Form package #150 for terminated or retired participants. Includes Form 150, Options Available upon Termination or Retirement document and the Special Tax Notice document.
Notice Of Changes Form #160 Notice Of Changes Form #160
Voluntary Account Withdrawal Request Form Package #170 Voluntary In-service Withdrawal Form Package #170 - Includes The Voluntary In-service Withdrawal Form and instructions, plus the Special Tax Notice document. This is for active employees who contribute voluntarily.
Rollovers Into HART Form #180 Rollovers Form #180 - Includes instructions for rolling prior plan money into this Plan and the address for mailing the rollover check.
Rollovers Into HART Form #180a Rollovers Form #180a - Includes instructions for rolling prior plan money into this Plan and the address for mailing the rollover check.
Request To Withdraw A Rollover Account Form #190 Request To Withdraw A Rollover Account Form #190
Loan Repayment Form #279 Loan Repayment Form #279 - Includes instructions for paying off a loan and the address for mailing the check.
Unknown Address Form #300 Unknown Address Form #300 - Used to submit infomation on employees who cannot be located.
HART Access Authorization Form HART Access Authorization Form
Loan Provisions Loan Provisions
Retiree Life Insurance Enrollment Form Retiree Life Insurance Enrollment Form
Rate Table For Retiree - Minnesota Life Rate Table For Retiree - Minnesota Life

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