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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

Designation of Beneficiary

To change your beneficiary information. This form is for active members only.

(RS5127, Rev. 11/11)

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Pensioner’s Designation of Beneficiaries

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.

(RS4411, Rev. 9/06)

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Designation of Beneficiary — Trust

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.

(RS5127-T, Rev. 3/11)

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Contact Information Changes

Change of Address Form

To change your address (for active members only). Retirees should contact us to change their address.

(RS5512, Rev. 11/12)

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Name Change Notice

To change your name (for active members only). Retirees should contact us to change their name.

(RS5483, Rev. 2/11)

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Contributions

Refund of Excess Contributions

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 contributions prior to retirement. This is a 4 page form. Please return pages 1 & 4.

(RS5195, Rev. 7/04)

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Section 21(l) Election Form

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)

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Section 21(l) or 321(l) Cancellation Form

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)

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Death Benefits

Application for Accidental Death Benefit

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)

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Notification of Death

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

(RS6082, Rev. 7/02)

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Survivor’s Benefit Program

Due to eligibility requirements, these forms are not available via our website. You must contact us to order a copy:

RS6361-B (Designation of Beneficiaries) (Rev. 2/08)

RS6357 (Non-member Employee Designation of Beneficiary for Eligible Employees of a New York State (NYS) Agency) (Rev. 3/03)

N/A

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Retirement

Application for Service Retirement

This is a two page form, please submit both pages.

(RS6037, Rev. 6/13)

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Withdrawal of Application for Service Retirement

(RS6354, Rev. 8/11)

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Request for Estimate

This is a two page form, please submit both pages.

(RS6030, Rev. 8/11)

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Option Election

Tier 1 Members, one beneficiary

(RS6109-A, Rev. 12/04)

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Tier 2 Members, one beneficiary

(RS6163, Rev. 12/04)

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Tier 1 Members, multiple beneficiaries

(RS6268, Rev. 12/04)

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Tier 2 Members, multiple beneficiaries

(RS6352, Rev. 12/04)

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Tier 3, 4, 5 and 6 Employees’ Retirement System (ERS) Members, one beneficiary

(RS6399, Rev. 4/13)

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Tier 3, 4, 5 and 6 ERS Members, multiple beneficiaries

(RS6400, Rev. 4/13)

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Option Election with Partial Lump Sum Payment (for Police & Fire Members only)

Tier 1 Members, one beneficiary

(PF6419-A, Rev. 8/13)

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Tier 2, 3, 5 and 6 Members, one beneficiary

(PF6421-A, Rev. 8/13)

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Tier 1 Members, multiple beneficiaries

(PF6420-A, Rev. 8/13)

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Tier 2, 3, 5 and 6 Members, multiple beneficiaries

(PF6422-A, Rev. 8/13)

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Disability Retirement Benefits

If you are terminally ill, you will want to file an 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.

Article 14 Disability Retirement Application

For Tier 3 Employees’ Retirement System members and Tier 3 Police and Fire Retirement System members covered by Article 14 benefits. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6411, Rev. 12/13)

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Article 14-B Disability Retirement Application

For county sheriffs, undersheriffs and certain deputy sheriffs whose employers elected coverage under Sections 555, 556, 557 and 558 of the Retirement & Social Security Law (RSSL). This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6408, Rev. 12/13)

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Article 15 Disability Retirement Application

For Tier 3, 4, 5 and 6 members. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6340, Rev. 12/13)

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605-A Accidental Disability Retirement Application

For court officers and peace officers in the Unified Court System. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6410, Rev. 12/13)

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Environmental Conservation & Regional State Park Police Disability Retirement Application

For State Environmental Conservation and Regional State Park police officers covered by Section 363-e (RSSL). This is a two page form and a HIPAA waiver, please submit all three pages.

(PF6091, Rev. 12/13)

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507-A Disability Retirement Application

For Tier 3, 5 and 6 NYS correction officers and security hospital treatment assistants. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6409, Rev. 12/13)

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Ordinary Disability Retirement Application

For PFRS members and Tier 1 and 2 ERS members. This application is not for Tier 3 members covered under Article 14. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6038, Rev. 12/13)

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Performance of Duty Disability Retirement Application

For NYS correction officers and security hospital treatment assistants who are covered by Chapters 653 and 722 (RSSL). This application is not for Tier 3 PFRS members covered under Article 14. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047-A, Rev. 12/13)

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Performance of Duty Disability Retirement Application

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 and a HIPAA waiver, please submit all three pages.

(RS6047-B, Rev. 12/13)

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Accidental Disability Retirement Application

For Police & Fire Retirement System members and Tier 1 and Tier 2 Employees’ Retirement System members. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047, Rev. 12/13)

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Performance of Duty Disability Retirement Application

Application for Police & Fire Retirement for Disability Incurred in Performance of Duty. This application is not for Tier 3 PFRS members covered under Article 14. This is a two page form and a HIPAA waiver, please submit all three pages.

(PF6047, Rev. 12/13)

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State Police Disability Retirement Application

For Tier 1, 2, 5 and 6 members and officers employed by the Division of NYS Police. This is a two page form and a HIPAA waiver, please submit all three pages.

(PF6090, Rev. 12/13)

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Application for World Trade Center Notice

Notice for those involved in the rescue, recovery or clean up operations of the World Trade Center aftermath. The deadline for filing the WTC notice was 9/11/10. If you filed your notice of participation with another NYS pension system by 9/11/10, please complete this form.

(RS6047-N, Rev. 6/09)

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World Trade Center Accidental Presumption Application

Application for those involved in the rescue, recovery or clean up operations of the World Trade Center aftermath. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047-W, Rev. 12/13)

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Application for Conversion of Service or Disability Retirement to Accidental Death Benefit for Victims of the 2001 World Trade Center Disaster

For beneficiaries of World Trade Center disaster victims. A beneficiary must file this application to convert a deceased retiree’s pension benefit to an accidental death benefit.

(RS6418-W, Rev. 12/13)

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Authorization for Release of Health Information Pursuant to HIPAA

HIPAA forms must be submitted with all disability applications.

(RS6429, Rev. 4/11)

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Loans

Before completing a loan application:

Please note that the following loan forms only apply to members of the NYS & Local Employees’ and Police and Fire Retirement System. 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

For all Tier 1 and 2 members (ERS and PFRS) who have annuity savings 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. 6/11)

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Tiers 3, 4, 5 & 6 Loan Application

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. 1/14)

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Membership

Tier Reinstatement Application

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 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)

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Transfer Membership

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

(RS5223, Rev. 8/09)

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Transfer of Membership in Accordance with Chapter 390

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)

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Withdrawal Application

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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Service Credit

Military Service Application

To apply for retirement credit for your military service under Article 20 of the RSSL.

(RS5509, Rev. 2/06)

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Service Determination Request

To request your total service credit recorded by the Retirement System.

(RS6277, Rev. 7/03)

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Request for Previous Service

To request credit for your public service before you became a member of the Retirement System. (Note: this form is 8½ by 14 inches).

(RS5042, Rev. 6/11)

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Application for Direct Trustee-to-Trustee Transfer for Purchase of Service Credit

To request the direct transfer of funds from a qualified plan in order to purchase optional service credit.

(RS2416, Rev. 12/13)

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Special Retirement Plans

20-Year Retirement Plan (Section 384-d) Election Form

For Police & Fire Retirement System (PFRS) members whose employers have adopted this plan.

(PF5117, Rev. 10/11)

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25-Year Retirement Plan (Section 384) Election Form

For PFRS members whose employers have adopted this plan.

(PF5095, Rev. 2/01)

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Withdrawal from 25-Year Retirement Plan (Section 384)

Allows PFRS members who elected this plan to withdraw from it after one year of coverage.

(PF5094, Rev. 10/02)

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Withdrawal from 20-Year Retirement Plan (Section 384-d and 384-e)

Allows PFRS members who elected this plan to withdraw from it after one year of coverage.

(PF5466, Rev. 1/03)

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Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 25-Year Retirement Plan Under Article 14-B

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.

(RS5495, Rev. 3/11)

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Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 25-Year Additional 1/60 Retirement Plan Under Article 14-B (Section 551(e))

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.

(RS5496, Rev. 3/11)

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Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 20-Year Retirement Plan Under Article 14-B

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.

(RS5497, Rev. 3/11)

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Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 20-Year Additional 1/60 Retirement Plan Under Article 14-B (Section 553)

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.

(RS5498, Rev. 3/11)

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Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 20-Year Retirement Plan with Additional 1/60 Under Article 14-B (Sections 552 and 553)

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.

(RS5498-A, Rev. 3/11)

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Election Form for Sheriffs, Undersheriffs and Deputy Sheriffs 25-Year Retirement Plan with Additional 1/60 Under Article 14-B (Sections 551 and 551(e))

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.

(RS5501, Rev. 3/11)

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Retiree Forms

W4P

To adjust your federal income tax withholding from your retirement benefit.

(Rev. 8/09)

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Electronic Funds Transfer Direct Deposit Enrollment Application

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.

(RS6370, Rev. 7/13)

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Notification of Death

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

(RS6082, Rev. 7/02)

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Where My Assets Are

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

(VO1848, Rev. 8/14)

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Pensioner’s Designation of Beneficiaries

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.

(RS4411, Rev. 9/06)

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Tier 2/3/4 Post Retirement Death Benefit Two Designation of Beneficiaries

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)

PDF Adobe pdf

NOTE: Retirees should contact us to order a change of beneficiary form specific for retirees (or to change their address).

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Employer Forms

Reporting Your Employees to the Retirement System:
Employees

Standard Work Day Resolution for non-Elected/Appointed Officials

(RS2418, Rev. 7/11)

PDF Adobe pdf
Elected and Appointed Officials

Standard Work Day and Reporting Resolution for Elected and Appointed Officials

(RS2417-A, Rev. 3/14)

PDF Adobe pdf

Standard Work Day and Reporting Resolution Continuation Form for Elected and Appointed Officials

(RS2417-B, Rev. 3/14)

PDF Adobe pdf

Recertification of the Record of Activities

(RS2419, Rev. 9/12)

PDF Adobe pdf
For more information about reporting requirements, review our Elected/Appointed Officials presentation.
Employee/Independent Contractor Certification Forms

For those hired on or after April 1, 2008

(RS2414, Rev. 10/11)

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For those hired before April 1, 2008

(RS2415, Rev. 10/11)

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Accidental Death Benefits Application

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)

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Adjustment Report

The Adjustment Report form is used to make corrections to the salary, service and/or contributions listed on previous monthly reports.

(RS2050, Rev. 1/14)

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Adjustment Report Label

Used with Adjustment Report.

(RS2050-A, Rev. 2/12)

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Employees’ Retirement System Membership Registration Application

To register new ERS members. This is a four page form, please submit all pages.

(RS5420, Rev. 5/13)

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Forms Order

To order Retirement System forms and publications.

(RS1165, Rev. 12/10)

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Monthly Salary & Service Certification

To certify a member’s previous employment.

Please note that overtime pay in excess of an annual cap is not included in the definition of salary for Tier 5 members. It should not be reported to the Retirement System and cannot be used in a final average salary calculation.

The overtime cap for calendar year 2010 and all years preceding 2010 is $15,000. The maximum reportable overtime increases by 3 percent each calendar year. To view the Employees’ Retirement System overtime limits table, please refer to our Tier 5 information.

(RS5120, Rev. 11/11)

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Notification of Death

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)

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Notification of Death

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)

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Police and Fire Membership Application

To register new PFRS members.

(PF5022, Rev. 5/13)

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Retirement Internet Reporting (RIR) — Electronic Debit Authorization Form

To have your monthly retirement payments debited from your account electronically.

(Rev. 3/14)

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Retirement Internet Reporting (RIR) — Employer Certification Form

To certify report information is correct and designate a security coordinator.

(Rev. 2/12)

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Statement of Accrued Payments and Leave Credits

To certify a member’s payments and credits. Must be completed before the member’s retirement can be completed.

(RS6221, Rev. 7/09)

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Survivor’s Benefit Program

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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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)

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General Forms

Public Retirement System Special Power of Attorney Form

(This form is limited to retirement benefit transactions and does not apply to any other matters.)

(Rev. 11/10)

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