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Are you inactive or withdrawn from a New York State or New York City p ublic retirement system?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
