HRSA-ILA Forms

HRSA-ILA Forms

If you are unable to print out any of the following forms, call the IVR at 757-423-3090 or the Participant Services Department at 757-457-7090 to enter your request and one will be mailed directly to you. If you choose to fill out the form on-line, be sure to hit the reset button after printing. All forms have to be signed for validation and mailed or faxed to the Funds address below.

General
Container Royalty

Change of Address Annuity Deduction & Tax Election

Direct Deposit Cancellation Direct Deposit

W4 Federal Tax Election Welfare

VA-4 State Tax Withholding Beneficiary Designation

Annuity
Medicare Direct Deposit

New Enrollment MILA Enrollment

Payroll Voluntary Deduction Delta Dental Healthy Smiles Enrollment - Diabetes

Investment Transfer

Beneficiary Designation
Delta Dental Healthy Smiles Enrollment - Pregnancy

Pension

Scholarship

Direct Deposit
Financial Aid Declaration

Beneficiary Designation Undergraduate Application

VA-4P State Withholding Graduate Application

W-4P Federal Tax Withholding YMCA

Vacation & Holiday
YMCA Pension Deduction Form

Annuity Deduction & Tax Election

Direct Deposit

Learn how to obtain birth certificates and
other vital information from the State of Virginia.
Medical Library Available to the Public. Use the botton below to access the Library through the Eastern Virginia Medical School.

HRSA-ILA Participant Services
Phone: 757-457-7090 | 1-800-899-3090 | Fax: 757-423-1205
Interactive Voice Response (IVR) 757-423-3090