HART Forms

In order to serve you better, HART’s forms are now editable. With an editable form, you can enter the required information using your computer or other device* instead of writing your responses by hand. The completed form can then be printed, signed and submitted to HART for processing.

By submitting forms that were filled in using your computer or other device, you help to reduce the errors and confusion that can sometimes occur with hand-written responses. This allows us to process your forms more quickly and efficiently, and to provide better service for you!

 Enrollment KitEverything you need to get enrolled into the HART Plan.
Form #120 Change of Address Form to update current mailing address.
Form #140 Change of BeneficiaryHave you had a Life Event? A marriage, birth of a child, divorce, etc. Complete form to update beneficiary information.
Form #160 Notice Of ChangeRequest to correct date of birth, date of hire, name change or social security number.
Form #170 Voluntary Account Withdrawal Request FormRequest withdraw of active employee’s voluntary contributions, plus the Special Tax Notice document.
Form #180A Rollovers Into HARTInstructions and form to complete to transfer funds into the HART plan from a qualified retirement plan.
Form #190 Request To Withdraw A Rollover AccountUse this form to request a withdraw of any money that was rolled into the HART Plan from a previous employer.
Form #279 Loan Repayment FormInstructions for paying off a loan and the address for mailing the check.
 Unknown Address Form #300Unknown Address Form #300 – Used to submit information on employees who cannot be located.
 HART Access Authorization FormForm to request access for person(s) to Plan related data through the Plan Sponsor Website
Form #130 Age 55 or Older ProvisionRequest distribution(s) or to set up recurring monthly or quarterly installment payments. ONLY for terminated or retired employees,age 55 or older.
Form #150 Request For Benefit PaymentRequest for terminated and retired employees to withdraw funds. Includes ALL distribution options available from HART, plus Special Tax Notice.
Retiree Life Insurance Enrollment FormRequest for life insurance coverage to be continued. This is for retiring employees, age 55 or older, with at least 10 years of service and participated in the Housing Authority life insurance program. Limitations may apply.
Rate Table For Retiree – Minnesota LifeChart provides retiree life insurance coverage & monthly premium cost by age.