Employees’ Retirement System
Membership Registration
RS 54 20
(Rev. 7/18)
F ax Number (518)486-4382
P lease type or print clearly
i
n blue or black ink
NYSLRS ID
Social Security Number *
Plan Tier Rate Date of Membershi p (mm/dd/yyyy
Registration Number
Part 1: Employee Read information provided on page 2. Complete Part 1 and sign at the bottom of the form.
Employee’s Name: (First, Middle Initial, Last)
Employee’s A
ddress: (Including Street, Apt No and/or PO Box, City, State and Zip Code)
Former Name: (if applicable)
Date of Birth (mm/dd/yyyy) Gender
M F
Are you receiving or about to receive a pension from a New York State or New Yor
k City p ublic retirement system? Yes No
If yes, please indicate name of system:
Are you inactive or withdrawn from a New York State or New York City p ublic retirement system? Yes No
If yes, please indicate name of system:
(NYS Teachers’, NYS Employees’, NYS Police and Fire, NYC Police Pensi
on Fund, NYC Fire Pension Fund, NYC Board of Education, NYC
Teachers’, NYC Employees’)
Part 2: Employer See page 2 for additional information and instr
uctions regarding the completion of this form.
Received Date
)
_______________________________________________________________________________________
_______________________________________________________________________________________
Employer’s Name: (Indicate State,or name of public entity by which employed and Department, Division or Institution)
Employer’s Address: (Including Street, City, State and Zip Code)
Employer’s Telephone Employer’s Fax Number Employee’s Payroll Title (Job Code) [1]
*Hire Date
Month Day Year
Date of Full-Time Permanent
Appointment
Month
Day Year
For a Substitute, Seasonal, On Call or Per Diem employee,
please check if he/she is working on the day t he application
is being submitted. Yes
____________________
$_______ $_______ $_______ $_______ _______
____________________________________________________ _____________________________________
Employee Classification
12 Month 10 M
onth 12 Month Provi
sional
Seasonal Substitute On Call Per Diem
Regular
Temporary
Full Time
Part T
ime
Loca
tion Code Re
port Code
Check if Either Applies
Elected Official
Appointed Official
For State Agency Use Only
Agency Code:
Frequency of Payment
Weekly Bi-Weekly Semi- Monthly Monthly Quarterly Semi- Annually Annually Other- Please Specify
Basis of Comp
ensation and Rate
Annual Daily Hourly Units of Work Per
formed per (Example: $50 per meeting or per examination etc)
Projected Annualized Wage
[2] Tier 6 requires employers to determi
ne the Annual Wage for individuals who work Part-Time, Seasonal or on an
Hourly, Daily or Unit of Work Basis. See back of this page for examples.
Important: If your employee is on a part-time, temporary or provisional basis, or less than 12 months a year, membership is optional. If your
membership is optional you must sign and date below to affirm Retirement System Membership.
I acknowledge that my membership in the New York state and Local Retirement System is governed by provisions of Article 15 of the Retirement and
Social Security Law and that I am entitled to all the benefits thereof. I understand that, as required by law, a deduction will be made from my salary or
compensation for retirement contributions
.
Signature: Date:
Employee’s Telephone Number: Employee’s Email Address:
For important information and instructions See Back Page
$_______
Part 1 – Employee Instructions
Important: If your employment is on a part-time, temporary or provisional basis, or less than 12 months a year, membership is optional.
If your membership is optional and you do not wish to join the Retirement System, do not complete this application.
Warning: If you are receiving or are about to receive a pension from another New York State or New York City public retirement system,
contact us directly before enrolling in NYSLRS. Enrollment may result in suspension of your pension benefit. NYSLRS retirees should
contact us directly before enrollment to discuss working after retirement and possible restoration of membership.
Membership Information:
If you are currently an active or vested member of any other public retirement system in New York State, you should contact that
system concerning the advantages of transferring your membership to this System. Failure to contact that system could cause loss of
the privilege of transferring membership and may affect contribution cessation dates.
If you were previously a member of any public retirement system in New York State, and your membership was terminated
or withdrawn, you may be eligible for a reinstatement of that membership. It is highly recommended that if you have a prior
Tier 1 or 2 membership in any New York public retirement system that you complete the Tier Reinstatement application,
RS5506 and attach it with your membership registration application.
You may also be eligible to receive credit for public service earned with a participating employer before your current date of
membership. This additional service may impact your future benefits.
You are covered by the Death Benefit allowed by law for your tier and plan status. If you have not already done so, complete an
RS5127 Designation of Beneficiary with Contingent Beneficiaries form to designate beneficiary(ies) to receive an Ordinary Death
Benefit. If there is no RS5127 Designation of Beneficiary with Contingent Beneficiaries on file with this System, your Ordinary Death
Benefit will become payable to your estate.
Part 2 – Employer Instructions
Field Explanation and information:
(1) Employee Payr oll Title If the title is accountant, auditor, physician, attorney, engineer or ar chitect, please submit documentation as
indicated at ww w.osc.state.ny.us/retire.employers/classify_an_employee.php.
(2) Projected Ann ual Wage- Examples of Tier 6 annual wage for individuals paid at an Hourly, Daily or Unit of Work basis of
compensation:
Hourly Employees
12 month Employe
e
e:
X ________ X = $________
Hourly
Rate
Standard
Workday
260
Days
Worked
Annual
Wage
10 month Employee: $_______X ________ X = $________
Hourly
Rate
$_______ X ________ X = $________
$_______X ________ X = $________
$______________ X________________ = ________________ X =
Standard
Workday
180
Days
Worked
Annual
Wage
Daily Employees
12 month Employee:
Daily
Rate
Standard
Workday
260
Days
Worked
Annual
Wage
10 month Employee:
Daily
Rate
Standard
Workday
180
Days
Worked
Annual
Wage
Unit of Work
Employees
Unit
Rate
# of
Events**
*
*Estimated or
Actual
Annual
Wage
Un
it of
Work Employee Example: Paid $50 per Meeting
$ 50
Unit Rate
12 Meetings
#of
Events***
***An estimate of the number
of
events is acceptable
$ 600
Annual
Wage
Note: Any
questions
regarding annual w
age,
please contact
the Retirement
System.
*Social Security Disclosure Requirement
In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of your Social Security account number is
mandatory pursuant to Sections 11, and 34 of the Retirement and Social Security Law. The number will be used in identifying
retirement records and in the administration of the Retirement System.
Personal Privacy Protection Law
The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide
information may interfere with the timely payment of benefits. The System may be required to provide certain information to
participating employers. The official responsible for record maintenance is the Director of Member and Employer Services, NYS and
Local Retirement System, Albany, NY 12244; call toll-free at 1-866-805-0990 or 518-474-7736 in the Albany Area.
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