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NYS Comptroller

Thomas P. DiNapoli

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.

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Member Forms

Beneficiary Changes

The quickest way to view and update your beneficiaries is by using Retirement Online, our secure, self-service web application.

Contact Information Changes

You can update your contact information by using Retirement Online, our secure, self-service web application.

Contributions

  • Refund of Excess Contributions Adobe pdf

    For Tier 1 & 2 members (and Tier 3 & 5 Police and Fire Retirement System (PFRS) members who are non-contributory) who voluntarily contribute to the Retirement System and want a refund of their member contributions prior to retirement. This is a four-page form. Please submit pages 1 & 4.

    (RS5195, Rev. 7/04)

  • Section 21(l) Election Form Adobe pdf

    For Tier 1 & 2 members (and Tier 3 & 5 PFRS members who are non-contributory) who want to begin making voluntary contributions to the Retirement System for an annuity at retirement.

    (RS5379, Rev. 4/10)

  • Section 21(l) or 321(l) Cancellation Form Adobe pdf

    For Tier 1 & 2 members (and Tier 3 & 5 PFRS members who are non-contributory) who want to discontinue making voluntary contributions to the Retirement System.

    (RS5378, Rev. 12/06)

Death Benefits

  • Application for Accidental Death Benefit Adobe pdf

    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.

    (RS6046, Rev. 12/13)

  • Notification of Death Adobe pdf

    Your survivors or employer should contact us to notify the Retirement System of your death so benefits can be paid to your beneficiary(ies), if applicable.

    (RS6082, Rev. 7/02)

  • Survivor’s Benefit Program

    Due to eligibility requirements, the following forms are not available via our website:

    • Designation of Beneficiaries (RS6361-B)
    • Non-member Employee Designation of Beneficiary for Eligible Employees of a New York State Agency (RS6357)

    You must contact us to order a copy.

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Loans

A convenient way to apply for a loan is by using Retirement Online, our secure, self-service web application.

Note: the following loan forms only apply to NYSLRS members. If you are a member of another public retirement system, please visit that system’s website for the appropriate forms.

  • Tiers 1 & 2 Loan Application Adobe pdf

    For all Tier 1 and 2 members (ERS and PFRS) who have annuity savings member 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 with all text showing — especially in the Notary area — or the form may be rejected.

    (RS5025, Rev. 6/17)

  • Tiers 3, 4, 5 & 6 Loan Application Adobe pdf

    For Tier 3, 4, 5 & 6 members (covered by Articles 14, 15 or 22). 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 with all text showing — especially in the Notary area — or the form may be rejected.

    (RS5025-A, Rev. 6/17)

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Membership

  • Tier Reinstatement Application Adobe pdf

    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.

    Note: Page 2 is 8½ by 14 inches. 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.)

    (RS5506, Rev. 8/13)

  • Transfer Membership Adobe pdf

    To transfer your current Retirement System membership to another public retirement system in NYS.

    (RS5223, Rev. 8/09)

  • Transfer of Membership in Accordance with Chapter 390 Adobe pdf

    To transfer a previously transferred Employees’ Retirement System membership from the Police and Fire Retirement System back into the Employees’ Retirement System.

    Note: You must be currently covered by Section 384-d, including 384-e or 381-b of the Retirement & Social Security Law (RSSL).

    (PF5467, Rev. 12/09)

  • Withdrawal Application Adobe pdf

    To withdraw your Retirement System membership. This is a four-page form. Please submit all four pages.

    (RS5014, Rev. 11/12)

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Retirement — Service

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Retirement — Disability

If you are terminally ill, you will want to file a payment option election form along with your disability retirement application. For more information, please read Processing Your Application in our publication, Life Changes, Applying for Disability Retirement.

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Option Election

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Option Election with Partial Lump Sum Payment

These forms are for eligible Police & Fire members, county Correction Officers, Sheriffs, Undersheriffs and Deputy Sheriffs only.

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Service Credit

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Special Retirement Plans

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Retiree and Beneficiary Forms

Death Benefits

  • Tier 2, 3, and 4 Post-Retirement Death Benefit Designation of Beneficiaries Adobe pdf

    The quickest way to view and update your beneficiaries is by using Retirement Online, our secure, self-service web application. The paper form is to be used only for those already retired to change the beneficiary to receive their post-retirement death benefit. This form will be deemed invalid if received before your date of retirement. This beneficiary does not have to be the same as the retirement option beneficiary. This is a two-page form. Please submit both pages.

    (RS4471, Rev. 9/06)

  • Pensioner’s Designation of Beneficiaries Adobe pdf

    To be used only for those already retired and receiving a pension (who retired under payment option ½, 1, 5-Year Certain, or 10-Year Certain). This is a two-page form. Please submit both pages.

    (RS4411, Rev. 9/06)

  • Notification of Death Adobe pdf

    Your survivors should contact us notify the Retirement System of your death so benefits can be paid to your beneficiary(ies), if applicable.

    (RS6082, Rev. 7/02)

Note: If you chose the Single Life Allowance option when you retired and you wish to change your beneficiaries for your Survivor’s Benefit for New York State Retirees, please contact us to request a Designation of Beneficiary Form (RS6361-B).

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Pension Payments

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Estate Planning

  • Where My Assets Are Adobe pdf

    Worksheet to help your survivors locate important documents/information upon your extended disability or death.

    (VO1848, Rev. 4/17)

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Employer Forms

Member Registration

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Reporting Employees

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Reporting Elected and Appointed Officials

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Employee/Independent Contractor Certification Forms

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Monthly Reporting

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Death Notifications and Benefits

  • Accidental Death Benefits Application Adobe pdf

    Can be filed by you on behalf of your deceased employee’s survivors within two years of your employee’s death.

    (RS6046, Rev. 12/13)

  • Notification of Death Adobe pdf

    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.

    (RS6082, Rev. 7/02)

  • Notification of Death – Survivor’s Benefit Program Adobe pdf

    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.

    (RS6358, Rev. 7/02)

  • Survivor’s Benefit Program Adobe pdf

    Eligibility of Retired Employee for Survivor’s Benefit.

    Note: This form is only to be used by New York State agencies and should be printed on legal (8½ by 14 inches) paper.

    (RS6355, Rev. 3/14)

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Retirement and Disability Related Forms

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Order Forms and Publications

  • Forms Order Adobe pdf

    To order Retirement System forms and publications.

    (RS1165, Rev. 7/17)

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General Forms

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