Fillable RetirementQuestionnaire2010

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RetirementQuestionnaire2010

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U.S.A. forms for Orange County Community College

BROWSE ORANGE COUNTY COMMUNITY COLLEGE FORMS

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ORANGE COUNTY COMMUNITY COLLEGE
MIDDLETOWN, NEW YORK 10940
RETIREMENT QUESTIONNAIRE
1. NAME SOC. SEC. NO.
2. ADDRESS
CITY STATE ZIP CODE
3. BIRTHDATE TELEPHONE
4. (A) IF YOU RETAIN AN ACTIVE CONTRACT WITH ONE OF THE FOLLOWING NEW YORK
STATE RETIREMENT SYSTEMS OR TIAA-CREF, YOU MUST INDICATE WHICH
RETIREMENT SYSTEM YOU ARE A MEMBER OF AND COMPLETE THE INFORMATION
REQUIRED.
NYS TEACHERS' RETIREMENT SYSTEM
REG. NO. DATE JOINED
TIER NO. CONTRIBUTION? YES NO
NYS EMPLOYEES' RETIREMENT SYSTEM
REG. NO. DATE JOINED
TIER NO. CONTRIBUTION? YES NO
TIAA CREF (TEACHERS' INSURANCE ANNUITY ASSOCIATION)
REG. NO. DATE JOINED
TIER NO. CONTRIBUTION? YES NO
SUNY CONTRACT NON-SUNY CONTRACT
DATE OF LAST PREMIUM DATE OF LAST PREMIUM
IF YOU HAVE RETIRED WITH AN INCENTIVE OR BEGUN WITHDRAWING FROM YOUR
ACCOUNT, YOU ARE NO LONGER ELIGIBLE FOR TIAA-CREF PARTICIPATION.
HAVE YOU RETIRED WITH AN INCENTIVE OR BEGUN WITHDRAWING FROM
YOUR ACCOUNT? YES NO
(B) IF YOU ARE A NEW FULL-TIME EMPLOYEE AND DO NOT BELONG TO A
RETIREMENT SYSTEM, YOU MUST CHOOSE ONE OF THE FOLLOWING WITHIN 30
DAYS OF EMPLOYMENT:
NYS TEACHERS' RETIREMENT SYSTEM
NYS EMPLOYEES' RETIREMENT SYSTEM
TIAA CREF (TEACHERS' INSURANCE ANNUITY ASSOCIATION)
Signature Date
IF YOUR EFFECTIVE DATE IN ANY OF THE ABOVE RETIREMENT SYSTEMS IS JULY 1, 1976,
OR LATER, YOU WILL BE REQUIRED TO CONTRIBUTE A PERCENTAGE OF YOUR GROSS
SALARY TOWARD YOUR RETIREMENT BY PAYROLL DEDUCTION.
**** OVER ****
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(C) PART-TIME EMPLOYEES:
IF YOU ARE NOT A MEMBER OF A NYS RETIREMENT SYSTEM, PLEASE READ THE FOLLOWING.
PART-TIME EMPLOYEES' ARE ELIGIBLE TO JOIN EITHER NYS TEACHERS' RETIREMENT SYSTEM
OR NYS EMPLOYEES' RETIREMENT SYSTEM (DEPENDING ON YOUR JOB TITLE).
IF YOU CHOOSE TO JOIN A RETIREMENT SYSTEM, A PERCENTAGE OF YOUR GROSS SALARY
WILL BE DEDUCTED AS YOUR CONTRIBUTION TO THE RETIREMENT SYSTEM.
**IMPORTANT**
THE FOLLOWING ACKNOWLEDGMENT MUST BE READ AND COMPLETED.
I HEREBY ACKNOWLEDGE THAT I HAVE BEEN INFORMED BY ORANGE COUNTY COMMUNITY
COLLEGE (EMPLOYER), AND THAT AS AN EMPLOYEE NOT CURRENTLY A MEMBER OF NYS
TEACHERS' RETIREMENT SYSTEM OR NYS EMPLOYEES' RETIREMENT SYSTEM
AND WHO IS OR WILL BE RENDERING LESS THAN FULL-TIME SERVICE, I MAY, AS A MATTER OF
RIGHT, JOIN EITHER NYS TEACHERS' OR EMPLOYEES' RETIREMENT SYSTEM (DEPENDING ON JOB
TITLE).
I FURTHER ACKNOWLEDGE THAT I UNDERSTAND UNDER PRESENT LAW, IF I ELECT TO JOIN A
RETIREMENT SYSTEM, I MUST COMPLETE A MEMBERSHIP APPLICATION WHICH WILL BE FILED
WITH THE RETIREMENT SYSTEM IN ORDER TO BE EFFECTIVE.
AS A RESULT OF JOINING THE RETIREMENT SYSTEM, I WILL BE REQUIRED TO CONTRIBUTE,
PURSUANT TO ARTICLE 15 OF THE RSSL, A PERCENTAGE OF MY SALARY TO SAID RETIREMENT
SYSTEM.
IF I JOIN A RETIREMENT SYSTEM, MY BENEFICIARY WILL BE PROTECTED BY A DEATH BENEFIT
SHOULD I DIE IN SERVICE AFTER I HAVE BEEN CREDITED BY THE SYSTEM WITH ONE YEAR OF
SERVICE. UPON MEETING ELIGIBILITY REQUIREMENTS, I WILL BE ENTITLED TO A LIFETIME
PENSION AT AGE 55 OR A DISABILITY PENSION AT AN EARLIER AGE IF I BECOME PERMANENTLY
AND TOTALLY DISABLED FROM GAINFUL EMPLOYMENT.
I ALSO UNDERSTAND IF I DO NOT ELECT TO JOIN, I MAY BE UNABLE TO OBTAIN CREDIT AT A
LATER DATE FOR SERVICE RENDERED DURING THE PERIOD I WAS NOT A MEMBER.
I DO WISH TO JOIN:
TEACHERS' RETIREMENT EMPLOYEES' RETIREMENT
AND REQUEST THAT YOU SEND ME AN APPLICATION FORM.
DATE
SIGNATURE
PRINT NAME
_______________________________________________________________________________________
DO NOT WISH TO JOIN I
DATE
SIGNATURE
PRINT NAME
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Completed 28 February 2020

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