Retirement System Forms
Do you need a Retirement System form? Here are the forms for Members, Retirees and Employers that are in a Portable Document Format (.pdf) format. If you do not already have the PDF reader for your browser, you can download a free copy directly from Adobe Systems. The forms can be printed, completed, notarized and mailed to the Retirement System.
These documents are available in Adobe (.pdf 
) format, which requires an Adobe reader.
Member Forms
Designation of Beneficiary (RS5127): To change your beneficiary information. This form is for active members only. If you are retired and receiving a pension (and have retired under options 1/2, 1, 5 Year Certain, or 10 Year Certain), you should use form RS4411. This is a two page form, please submit both pages. (Rev 9/06)
Designation of Beneficiary - Trust (RS5127-T): To designate a trust as either your primary or contingent beneficiary. This form is for active members only. If you are retired and receiving a pension (and have retired under options 1/2, 1, 5 Year Certain, or 10 Year Certain), you should use form RS4411. (Rev 2/08)
Change of Address (RS5512): To change your address (for active members only). Retirees should contact us to change their address. (Rev 9/04)
Name Change Notice (RS5483): To change your name (for active members only). Retirees should contact us to change their name. (Rev 1/05)
- Excess Contributions Application (RS5195): For Tier 1 & 2 members who voluntarily contribute to the Retirement System and want a refund of their contributions prior to retirement. This is a 4 page form. Please return pages 1 & 4) (Rev 7/04)
- Section 21(l) Election Form (RS5379): For Tier 1 & 2 members who want to begin making voluntary contributions to the Retirement System for an annuity at retirement. (Rev 5/98)
- Section 21(l) or 321(l) Cancellation Form (RS5378): For Tier 1 & 2 members who want to discontinue making voluntary contributions to the Retirement System. (Rev 12/06)
- Accidental Death Benefit (RS6046): If you die while on the job as the result of an accident, this form should be submitted by your employer or survivors within two years of your death. This is a two page form, please submit both pages.
(Rev 1/03) - Notification of Death (RS6082): Your survivors or employer should notify the Retirement System of your death so benefits can be paid to your beneficiary(ies), if applicable. (Rev 7/02)
- Application for Service Retirement (RS6037): This is a two page form, please submit both pages. (Rev 2/05)
- Withdrawal of Application for Service Retirement (RS6354) (Rev 10/02)
- Request for Estimate (RS6030) - This is a two page form, please submit both pages. (Rev 7/09)
- Option Payment Selections (fill-in forms)
- Tier 1 Members, one beneficiary (RS6109) (Rev 12/04)
- Tier 2 Members, one beneficiary (RS6163) (Rev 12/04)
- Tier 1 Members, multiple beneficiaries (RS6268) (Rev 12/04)
- Tier 2 Members, multiple beneficiaries (RS6352) (Rev 12/04)
- Tier 3 & 4 Members, one beneficiary (RS6399) (Rev 4/05)
- Tier 3 & 4 Members, multiple beneficiaries (RS6400) (Rev 12/04)
- PLS Option Payment Selections (fill-in forms) (for Police &Fire Members only)
- Tier 1 Members, one beneficiary (PF6419-A) (Rev 11/08)
- Tier 2 Members, one beneficiary (PF6421-A) (Rev 11/08)
- Tier 1 Members, multiple beneficiaries (PF6420-A) (Rev 11/08)
- Tier 2 Members, multiple beneficiaries (PF6422-A) (Rev 11/08)
- Option Payment Selections (fill-in forms)
Disability Retirement Benefits (Please contact the Retirement System if you're not sure which application(s) to file)
- Accidental Disability Retirement Application (RS6047): For Police & Fire Retirement System members and Tier 1 and 2 Employees' Retirement System members. This is a two page form, please submit both pages. (Rev 1/03)
- Article 14 Disability Retirement Application (RS6411): For Tier 3 Employees' Retirement System members and Tier 2 Police and Fire Retirement System members who joined on or after July 1, 2009 and are covered by Article 14 benefits. This is a two page form, please submit both pages. (Rev 1/03)
- Article 14-b Disability Retirement Application (RS6408): For county sheriffs, undersheriffs and certain deputy sheriffs whose employers elected coverage under Sections 551, 552 and 553 of the Retirement & Social Security Law (RSSL). This is a two page form, please submit both pages. (Rev 12/08)
- Article 15 Disability Retirement Application (RS6340): For Tier 3 and 4 members. This is a two page form, please submit both pages. (Rev 6/03)
- Court Officers Accidental Disability (RS6410): For Court Officers & Peace Officers in the Unified Court System. This is a two page form, please submit both pages. (Rev 2/01)
- Environmental Conservation & Regional State Park Police Disability Retirement Application (PF6091): For State Environmental Conservation and Regional State Park Police Officers covered by Section 363-e (RSSL). This is a two page form, please submit both pages. (Rev 10/02)
- 507-A Disability Retirement Application (RS6409): For Tier 3 NYS Correction Officers and Security Hospital Treatment Assistants. This is a two page form, please submit both pages. (Rev 2/01)
- Ordinary Disability Retirement Application (RS6038): For PFRS members and Tier 1 and 2 ERS members. This is a two page form, please submit both pages. (Rev 8/05)
- Performance of Duty Disability Retirement Application (RS6047-A) For NYS Correction Officers and Security Hospital Treatment Assistants who are covered by Chapters 653 and 722 (RSSL). This is a two page form, please submit both pages. (Rev 12/08)
- Performance of Duty Disability Retirement Application (RS6047-B) For Sheriffs, Deputy Sheriffs, Undersheriffs and County Correction Officers in Counties that elected Sections 63-B, 63-C, 607C and 607D. This is a two page form, please submit both pages. (Rev 12/08)
- Performance of Duty Disability Retirement Application (PF6047): Application for Police & Fire Retirement for Disability Incurred in Performance of Duty.
(Rev 1/03) - State Police Disability Retirement Application (PF6090): For officers employed by the Division of NYS Police. This is a two page form, please submit both pages. (Rev 2/01)
- Application for World Trade Center Notice (RS6047-N): Notice for those involved in the rescue, recovery or clean up operations of the World Trade Center aftermath. (Rev 6/09)
- World Trade Center Accidental Presumption Application (RS6047-W): Application for those involved in the rescue, recovery or clean up operations of the World Trade Center aftermath. This is a two page form, please submit both pages. (Rev 6/09)
Before completing a loan application:
- Click here for information regarding IRS tax regulations.
- Click here for information regarding your deferred compensation or tax sheltered annuity plan.
- Tiers 1 & 2 Loan Application (RS5025): For Tier 1 & 2 members who have contributions on deposit with the Retirement System. Please make sure you read all pages and sign where necessary on page 2. We do not accept faxed loan applications. Note: Please make sure this form prints properly w/all text showing - especially in the Notary area - or form may be rejected.
(Rev 4/08) - Tiers 3 & 4 Loan Application (RS5025-A): For Tier 3 & 4 members. Please make sure you read all pages and sign where necessary on page 2. We do not accept faxed loan applications. Note: Please make sure this form prints properly w/all text showing - especially in the Notary area - or form may be rejected. (Rev 6/09)
- Tier Reinstatement Application (RS5506): To reinstate your previous Tier 1 or 2 date of membership in a public retirement system in NYS. This is a four page form. Please submit pages 1 & 4. (Printing Note: Page 2's format is 8 1/2 x 14. Depending on your browser and printer, to print it, you may need to use the print icon (or File/Print) from the Adobe Reader - select "Shrink to Fit" at bottom of print menu. You may not need to use this feature for pages 1, 3 or 4.) (Rev 8/03)
- Transfer Membership (RS5223): To transfer your current Employees’ Retirement System membership to another public retirement system in NYS. (Rev 7/05)
- Transfer Membership (PF5223): To transfer your current Police & Fire Retirement System membership to another public retirement system in NYS. (Rev 7/05)
- Application for Transfer of Membership in Accordance with Chapter 390 (PF5467): To transfer a previously transferred Employees’ Retirement System membership from the Police and Fire Retirement System back into the Employees’ Retirement System. Please note: you must be currently covered by Section 384-d, including 384-e or 381-b of the Retirement & Social Security Law. (Rev 12/09)
- Withdrawal Application (RS5014): To withdraw your Retirement System membership. This is a four page form. Please submit all four pages.
(Rev 12/02)
- Military Service Application (RS5509): To apply for retirement credit for your military service under Article 20 of the RSSL. (Rev 2/06)
- Service Determination Request (RS6277): To request your total service credit recorded by the Retirement System. (Rev 7/03)
- Supplemental Statement of Service (RS5042): To request credit for your public service before you became a member of the Retirement System. (Note: this form is 8 1/2 x 14). (Rev 7/02)
- 20-Year Retirement Plan (Section 384-d) Election Form (PF5117). For Police & Fire Retirement System (PFRS) members whose employers have adopted this plan. (Rev 10/02)
- 25-Year Retirement Plan (Section 384) Election Form (PF5095). For PFRS members whose employers have adopted this plan. (Rev 2/01)
- Withdrawal from 25-Year Retirement Plan (Section 384) (PF5094). Allows PFRS members who elected this plan to withdraw from it after one year of coverage. (Rev 10/02)
- Withdrawal from 20-Year Retirement Plan: (Section 384-d and 384-e) (PF5466). Allows PFRS members who elected this plan to withdraw from it after one year of coverage. (Rev 1/03)
- Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 25 Year Retirement Plan Under Article 14-B (RS5495): To be completed only by Sheriffs, Undersheriffs, or Deputy Sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available (Rev 5/06)
- Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 20 Year Retirement Plan Under Article 14-B (RS5497): To be completed only by Sheriffs, Undersheriffs, or Deputy Sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available (Rev 5/06)
Retiree Forms
- W4P: To adjust your federal income tax withholding from your retirement benefit. (Rev 8/09)
- Direct Deposit (Fill-in Form)(RS6370L-3): Use this to have your monthly benefit electronically deposited to your checking or savings account. Also used to change the bank where your benefit is deposited. This is a two page form, please submit page 1. (Rev 7/09)
- Notification of Death (RS6082): Your survivors should notify the Retirement System of your death so benefits can be paid to your beneficiary(ies), if applicable. (Rev 7/02)
- Where My Assets Are (VO1848): Worksheet to help your survivors locate important documents/information upon your extended disability or death.
(Rev 8/06) - Pensioner’s Designation of Beneficiaries (RS4411): To be used only for those already retired and receiving a pension (who retired under options 1/2, 1, 5 Year Certain, or 10 Year Certain). This is a two page form, please submit both pages. (Rev 9/05)
- Tier 2/3/4 Post Retirement Death Benefit Two Designation of Beneficiaries (RS4471): To be used by retirees to change the beneficiary to receive their post retirement death benefit. This beneficiary does not have to be the same as the retirement option beneficiary. This is a two page form, please submit both pages. (Rev 9/05)
NOTE: Retirees should contact us to order a change of beneficiary form specific for retirees (or to change their address).
Employer Forms
- Employee/Independent Contractor Certification Forms:
- Accidental Death Benefits Application (RS6046): Can be filed by you on behalf of your deceased employees' survivors within two years of your employee's death. (Rev 1/03)
- Adjustment Report (RS2050): To amend contribution overpayments to previous. monthly reports. (This application should be printed on Legal (8 1/2" x 14") paper) (Rev 3/08)
- Adjustment Report Label (RS2050-A): Used with Adjustment Report (RS2050) (Rev 9/08).
- January - June 2010 Consultation Site Schedule (VO1722): A six month schedule for our 16 statewide offices. (Rev 1/10))
- Election Form for Sheriffs, Undersherrifs and Deputy Sheriffs (RS5498-A): This election to be completed only by Sheriffs, Undersheriffs or Deputy Sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available. (Rev 1/03)
- Employees’ Retirement System Membership Application (RS5420): To register new ERS members. (This is a two-page form, please submit both pages. (Rev 1/10)
- Fax Registration (RS5494): To Register new employees via fax. (Rev 4/08)
- Forms Order (RS1165): To order Retirement System forms and publications.
(Rev 4/08) - Monthly Reporting Form (RS2402): To provide the Retirement System with a monthly total of salary earned and days worked for each of your employees.
(Rev 3/02) - Monthly Reporting Label Form (RS2403): Used with Monthly Reporting Form (RS2402) (Rev 2/02)
- Monthly Salary & Service Certification (RS5120): To certify a member's previous employment. (Rev 12/04)
- Notification of Death (RS6082): Your employee's survivors should notify the Retirement System of their relative's death so benefits can be paid to his or her beneficiary(ies), if applicable. (Rev 7/02)
- Notification of Death (RS6358): To notify the Retirement System of the death of your employee so any survivor benefits can be paid to his/her beneficiary(ies), if applicable. (Rev 7/02)
- Police and Fire Membership Application (PF5022): To register new PFRS members. (Rev 1/10)
- Statement of Accrued Payments and Leave Benefits (RS6221): To certify a member's payments and benefits. Must be completed before the member's retirement can be completed. (Rev 7/09)
- Survivor's Benefit Program (RS6355): Eligibility of Retired Employee for Survivor's Benefit. NOTE: This form is only to be used by New York State agencies. (This form should be printed on Legal (8 1/2" x 14") paper) (Rev 3/07)
- Section 211 Form - This form must be filed with the Department of Civil Service for retirees returning to work under Section 211. (Rev 4/07)