PSE Transfer

BENEFITS
Notice of Incoming PSE Transfer

Must be completed and submitted to TSS EBD by the Employee's NEW district.
Original Document

You are encouraged to review the original document prior to completing this form. Your answers will be embedded on the PDF form and submitted to the proper department.
Employee Name
Member # or SSN
Email Address
example@example.com
Dependents

YesNo
Transferring TO Information
School Name
Group #
District Name
Transferring FROM Information
School Name
Group #
District Name
Signature*

Clear
Date*

MonthDayYear
Date
Submit completed and signed form to TSS EBD_Eligibility by task through ARBenefits or via fax at 501-683-0983.

Transfer forms MUST be submitted to TSS EBD no later than: August 11, 2023.

Please have this Employee added in eFinance before sending a Notice of Incoming PSE Transfer form to TSS EBD.
Should be Empty:

BENEFITS