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Request for Previous Service
RS 5042
(Rev. 6/11)
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
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_
__________________
Name _____________________________________
(Print or Type)
D.O.B. _________________ Registration Number ______________________ S.S. Number ________________________
Previous Name
You May Have Been Using
By Whom Currently Employed
(Indicate whether State, County, City, Town, Village, Special District, etc.)
Department Where Now Employed ____________________________________________________
RECORD OF ADDITIONAL SERVICE NOT INCLUDED IN FORMER STATEMENT OF SERVICES INCLUDING MILITARY SERVICE
Public employer you
worked for during previous
services claimed (i.e-State,
County, Town, etc.)
Name of Department
or Agency for
that employer
Name of Retirement System
(If you were a member)
Registration Number
(During previous
membership-if known)
Title of Position(s)
FROM TO
LENGTH OF SERVICE
Mo. Day Year Mo. Day Year Mo. Day Year
This form is to request additional retirement service credit
ADDITIONAL TOTAL SERVICE CLAIMED
Current Home Address ___________________________________________________________________________
No. Street
_________
___________
City State Zip Code
Telephone Number
Signed ________________________________________________________________
