Fill - Free fillable Form 1: Tiers 1 & 2 Loan Application (State University of New York at Farmingdale) PDF form

(If you have loan balances outstanding with more than one employer retirement plan, please

provide the combined total of these balances in each section below):

Tiers 1 & 2

Loan Application

RS 5025

(Rev. 2/15)

Mail completed form to:

NEW YORK STATE AND LOCAL RETIREMENT SYSTEM

110 STATE STREET - MAIL DROP 5-9

ALBANY NY 12244-0001

Please see pages 3 and 4 for instructions on completing this form. We cannot accept faxed loan applications. If you are not sure you

are eligible for a loan, please call us toll-free at (866) 805-0990 or (518) 474-7736 in the Albany, New York area.

You must answer all questions in ink and the application must be signed and notarized, or it will be rejected.

Personal Information

A. Social Security Number Registration Number (if known)

Last Name First Name M.I.

Permanent Mailing Address

Street Address (Street or PO Box) Unit or Apt #

Street Address

City State Zip Code

Home Phone Work/Cell Phone Extension

B. Address to which you want your check sent (only if different from permanent mailing address)

c / o

Street Address (Street or PO Box) Unit or Apt #

City State Zip Code

- - -

( )

Receipt Date

Required Information– Must be Completed (See page 3 for instructions)

If you participate in another retirement plan offered through your employer (such as a 457 deferred compensation plan, 403-a qualied annuity

plan, 403-b tax sheltered annuity plan or 401 qualied trust), and have an existing loan through that plan, you must disclose this information

or this loan application will be rejected. If you have memberships in both PFRS and ERS, and have an existing loan in one System at the time

you apply for a loan in the second, you do not have to include this information below. The balances required will be included automatically when

you apply for your loan. The Internal Revenue Code requires us to consider these loan balances when we calculate the taxability of a loan from

our System. Note that this may result in signicant tax consequences on your loan from this System. (See tax information on page 4.)

A. Do you have an outstanding loan balance with your current employer through any of the retirement plans noted above?

No– Go to

Yes– You must answer the following

B. How much money do you currently have invested in the retirement plan(s) from which your

loan(s) was issued?

C. What is your current total balance outstanding on your plan loans(s)?

D. In the past 12 months, what was your highest loan balance through this plan(s)?

, .

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, .

0 0

, .

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The single repayment amount for multiple loans is higher than a single repayment on a renanced loan.

RS 5025 (Rev. 2/15) Page 2 of 4

See page 3 for important information and instructions. Before choosing a loan type, call our automated information phone line

toll-free at (866) 805-0990 or (518) 474-7736 in the Albany, New York area. Once you access the loan menu, you can receive

specic information relating to your account for multiple and renanced loans.

Notary Stamp

Loan Type– You must select ONLY ONE of the following or we cannot accept your application.

A. Loan Type 1 – Check here if you want a loan and do NOT have an existing loan with us.

Loan Type 2 – (This is called a multiple loan.) Check here if you already have a loan with us and want to take another loan.

Loan Type 3 – (This is called a renanced loan.) Check here if you already have a loan with us and want to add to it.

WARNING! The taxable amount for a renanced loan will always be greater than for a multiple loan, unless the entire amount of

the renanced loan is non-taxable. To avoid severe tax consequences, verify your taxable amount using our automated information line.

I am aware of the possible tax consequences of taking a renanced loan and authorize the Retirement System to process

my application as indicated.

¨ ¨

, .

0 0

, .

0 0

¨ ¨ ¨ ¨ ¨ ¨ ¨

¨ ¨ ¨

, .

0 0

Loan Amount

A. I am applying for (Choose only one):

i. A maximum NON-TAXABLE loan ii. A loan of: iii. A maximum loan

B. Loan Repayment Amount (per pay period)

Minimum OR

Higher Than Minimum

If you want to pay higher than the minimum required, and choose

Loan

ype 2 (multiple loans), your payroll loan deduction will remain

the same until all loans are paid or a new loan is taken.

C. Federal Tax Withheld – If your loan is taxable, Federal law requires us to withhold 10 percent of the taxable amount of this loan, unless you

check the box below (you may incur additional taxes and/or penalties if your withholding is insufcient). Federal withholding can signicantly

reduce the loan amount payable to you.

Do not deduct 10 percent withholding tax

Payroll Information

A. Employer (Employer payroll from which loan repayments will be deducted)

B. Annual Salary

C. Payroll Frequency (Check one box only)

Weekly Bi-Weekly Semi-Monthly Monthly Quarterly Semi-Annual Annual

D. Employment Term (Check one box only)

I am a 12-Month Employee I am a 10-Month Employee I am a Seasonal Employee

TO THE COMPTROLLER OF THE STATE OF NEW YORK:

I am applying for a loan from the Retirement System as shown above. I agree to deductions being taken from my salary for each future payroll period

until the total amount due, including interest, is repaid. I agree that my annuity savings account be charged with the required loan insurance premiums

until the loan is repaid. I agree that the rate of interest on this loan shall be xed by the Comptroller as provided for in the Retirement and Social Security

Law.

Signature (must be sign

ed in ink and acknowledged by a notary)

ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC

State of ___________________ County of ______________________ On the _____ day of ___________

in the year ________ before me, the undersigned, personally appeared ___________________________,

personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s)

whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they

executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument,

the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

NOTARY PUBLIC (Please sign and afx stamp)

PERSONAL PRIVACY PROTECTION LAW

In accordance with the Personal Privacy Law, you are hereby advised that pursuant to the Retirement and Social Security Law, the Retirement System is required to maintain records. The records are

necessary to determine eligibility for and to calculate benets. Failure to provide information may result in the failure to pay benets. The System may provide certain information to participating employers.

The ofcial responsible for maintaining these records is the Director of Member & Employer Services, New York State and Local Retirement System, 110 State Street, Albany, NY 12244-0001; Telephone

Number (518) 474-4608.

SOCIAL SECURITY DISCLOSURE REQUIREMENT

In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the 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.

BANKRUPTCY INFORMATION

A loan from the Retirement System based on a member’s contributions is not a debt and, therefore, is not dischargeable in bankruptcy.

RS 5025 (Rev. 2/15) Page 3 of 4

Instructions and Information For Filling Out Loan Application

Instructions

A. Complete the entire section.

B. Complete this section only if you want your check sent to an address other than your permanent mailing address. Give the name of the person (or

employer) the check should be mailed to in care of, otherwise it will be returned to us.

Personal Information

Required Information – Must be Completed

General Information

Your employer is a participating employer in The New York State & Local Retirement System (System). The System is a Section 401(a)

qualied trust. In addition to membership in the System, your employer may offer other types of retirement plans. Before we can issue

a loan to you, the Internal Revenue Service requires us to inquire whether you have outstanding loans in other retirement plans offered

by your employer. For this purpose, include loans from plans sponsored by the employer upon which your System membership is

based.

Loans from private sector employer plans or retirement accounts are not included.

Two common employer-sponsored retirement savings plans are:

Section 457, a deferred compensation plan, is a voluntary supplemental retirement savings plan sponsored by your current employer. It enables

public employees to save a portion of their gross pay before Federal and State income taxes are deducted.

Section 403(b), a tax sheltered annuity plan, is an employer-sponsored retirement savings program. By law, participation is limited to employees

of public educational organizations and certain nonprot organizations.

Other, less common employer-sponsored retirement savings plans are:

Section 403(a) qualied annuity

Section 401 qualied trusts

Loan Type

General Information

Choose only one type of loan. If you do not check any of the boxes, or if you choose more than one type of loan, your application will be rejected.

Instructions

A. Check Loan Type 1 only if you do not have an existing loan from us and are requesting one.

B. Loan Type 2 (multiple loan) allows you to take another, separate loan from us. Multiple loans have separate ve year due dates on which the minimum

payments are calculated. These minimum payments are then added together for a total minimum payment. That is why if you take another loan

under this option, you will have a higher minimum payment than if you renance. However, the payments for all loans will be combined so you only

have one payroll deduction.

C. Loan Type 3 (renanced loan) allows you to add the new loan amount to your existing loan balance and renance the entire amount as one loan

instead of taking another, separate loan. Minimum repayment amounts for renanced loans are less than multiple loans because we add on the

amount you are currently requesting to your existing loan. We then renance the total amount for another ve years. Because of the increased

taxable amount for a renanced loan, Federal withholding can signicantly reduce the loan amount payable to you.

Loan Amount

General Information

There are various tax thresholds and circumstances that determine when a loan is taxable and what portion of a loan is taxable. Before choosing

a taxable or non-taxable loan, you should call our automated information line to get specic information regarding the amount you want to borrow.

The maximum non-taxable loan amount will be less for a renanced loan (Loan Type 3) than for a multiple loan (Loan Type 2), unless the entire

amount of the renanced loan is non-taxable.

The taxable amount for a renanced loan (Type 3) will always be more than if you take a multiple loan (Loan Type 2), unless the entire amount of

the renanced loan is non-taxable.

When choosing the Loan Repayment Amount, you can choose either to repay the minimum amount or a higher than minimum amount each pay

period. The minimum amount will be based on your payroll frequency and how much you must repay each payroll period based on a ve-year

repayment plan. We will calculate what the minimum repayment is if you choose this option.

If you select minimum payment and have multiple loans, your payroll deduction will equal the total of the minimum payments for each loan. After

your oldest loan is repaid, your payroll deduction will be reduced by the amount you had been paying on that loan.

Instructions

A. Check one box to tell us how much you want to borrow. You have three choices:

i. A loan for the maximum non-taxable amount we can provide you by law (Box i)

ii. A specic loan amount, up to the maximum amount available (Box ii). You must enter the amount you want to borrow.

iii. A loan for the maximum amount we can provide you by law (a portion of this may be taxable) (Box iii)

B. You may repay more than the minimum amount, if you wish. Indicate the exact amount you want to repay each pay period. If you want to repay more

than the minimum amount and are requesting Loan Type 2 (multiple loans), your payroll loan deduction will remain the same until all loans are paid,

a new loan is taken, or you request in writing that your payment be changed to the minimum amount due.

C. Federal Tax Withheld – Federal law requires us to withhold Federal tax at a rate of 10 percent of the taxable amount of the loan unless you elect not

to have this automatic withholding apply. Federal withholding can signicantly reduce the loan amount payable to you.

Payroll Information

Instructions

A. Give us your employer’s full name so we can notify them to take loan deductions.

B. Provide your gross annual salary.

C. To determine your loan repayment amount, we need to know how often you are paid (check one box only).

D. Tell us what your term of employment is (check one box only).

Signature

We cannot accept your loan application unless it is signed.

Notary Public Acknowledgement

The application must be notarized or it will be rejected.

RS 5025 (Rev. 2/15) Page 4 of 4

ALL TIER 1 AND TIER 2 LOANS ARE SUBJECT TO THE FOLLOWING:

You must be in active service with the State or a participating employer

and have credit for at least one year of member service. Members on

a leave of absence are not considered to be in active service. If you

are retiring, your loan application must be received before your date of

retirement for it to be processed.

Only one loan may be granted every 90 days.

A loan may not be granted for less than $25.

The maximum loan permitted under law is 75 percent of the amount

you have on deposit in your contribution account, less any outstanding

loan balance. If the requested loan amount exceeds the legal limit, your

application will be processed for the maximum amount permitted.

The minimum repayments must be in an amount sufcient to repay the

loan within ve years and no less than $3.00 if paid weekly, $5.00 if

bi-weekly or semi-monthly, or $10.00 if monthly. Loan repayments are

in even dollar amounts and must be paid through payroll deductions.

If you leave the payroll, or you are on an authorized leave of absence,

please call us for information on repaying your loan. If you do not

make payments on your loan quarterly or complete payment within ve

years of the date the loan is issued, whichever comes rst, your loan

will be in default. At the time a default occurs, the entire amount due

on your loan, minus any previously taxed portion, must be reported to

the Internal Revenue Service (IRS) as a lump sum distribution from

a qualied plan. However, the balance on a defaulted loan is still

owed, and interest and insurance charges continue to accrue until

the balance is paid in full. If any of your loans are in default, you will

be unable to borrow from us in the future until the entire balance on all

loans in default has been repaid. If you are called to active military duty,

special rules apply. Please contact our Call Center.

WARNING! If you retire or withdraw from the Retirement System and

have an outstanding loan on the effective date of your retirement or

withdrawal, part or all of the loan balance may constitute taxable funds

which were credited to your account and, therefore, would be subject

to Federal income tax in the year in which you retire or withdraw.

Since this income would not be reportable until you retire or withdraw,

information regarding the amount will be furnished to you at that time.

Interest is charged on loans at the rate of 5 percent per annum, based

on the outstanding balance at the beginning of each month.

Loans are fully insured against the death of a member prior to

retirement. There is no insurance for the rst 30 days. Premiums to

cover the cost of this insurance are based on the amount of the loan

and your age, and are charged against your contribution balance at

the end of the year. Loan insurance does not cover you if you become

disabled or unemployed.

IMPORTANT BENEFIT INFORMATION

If you have an outstanding loan balance at the time of your retirement, your benet will be permanently reduced. The following table shows the

approximate annual reduction in benets for each $1,000 of loan outstanding at retirement if you retire at various ages:

EMPLOYEES’ RETIREMENT SYSTEM

Service Retirement Reductions

Age at Retirement

Annual Reduction

$84.95

$90.65

$93.48

$98.49

$109.83

POLICE & FIRE RETIREMENT SYSTEM

Service Retirement Reductions

Age at Retirement

Annual Reduction

$77.34

$80.78

$85.70

$92.63

$96.10

$102.23

IMPORTANT FEDERAL TAX INFORMATION

Existing loans with a deferred compensation or tax sheltered annuity plan: If you have an existing loan from one of these plans, both the current

loan balance and the current contribution balance will be taken into account when calculating the taxability of the loan from this system.

1. Loans over $50,000:

No outstanding loan when new loan granted: Loans that exceed $50,000 must be reported to the IRS as a distribution from a qualied plan to the

extent that the loan exceeds $50,000, less the highest outstanding loan balance in the past 12 months.

Renanced Loan: Renanced loans that cause the outstanding loan balance at the time the new loan is granted (old balance) when added to the

replacement loan (old balance plus the new loan amount) to exceed $50,000, less the difference between the highest total outstanding balance

during the past year and the ‘old balance,’ must be reported to the IRS as a distribution from a qualied plan to the extent that the loan exceeds this

amount.

Multiple Loans: Loans that cause the loan account (total of all outstanding loans plus the new loan) to exceed $50,000, less the difference between

the highest total outstanding balance during the past year and the total old balance (total of all outstanding loans prior to new loan), must be reported

to the IRS as a distribution from a qualied plan to the extent that the loan account exceeds this amount.

Any portion of the distribution amount that cannot be offset by your after-tax contribution will be reported to the IRS as ordinary income.

2. Loans under $50,000:

If there is no outstanding loan or a separate multiple loan is granted, and the new loan results in the total ‘outstanding balance’ being more than

the greater of (a) $10,000 or (b) 50 percent of the present value of your accrued non-forfeitable benet, the amount over that gure will be reported

to the IRS as ordinary income for the current year. If you are not vested, the present value of your accrued non-forfeitable benet is equal to your

contribution balance. If you are vested, the present value of your accrued non-forfeitable benet is an actuarially determined amount. For renanced

loans, the ‘outstanding balance’ is the total of both the loan balance at the time the new loan is granted and the renanced loan amount (which

includes the loan balance at the time the new loan is granted).

3. If you go off the payroll, or your loan payments stop prematurely, contact the Call Center to make arrangements to repay your loan directly. If

you do not make payments on your loan at least once every three months, or do not complete repayment within ve years from the date the loan is

issued, your loan will default. When a loan defaults, the outstanding balance, minus any previously taxed amount, must be reported to the IRS as

ordinary income.

4. If you are under age 59½ at the time any part of your loan becomes reportable, you may be subject to an additional 10 percent penalty tax. The

Federal Internal Revenue Code imposes this penalty tax on amounts deemed to be a distribution prior to your actual retirement.

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