Pop-Up
Joint Allowance- Partial
I elect to receive a reduced lifetime retirement allowance based on my life expectancy
and the life expectancy of my beneficiary. If I die before my beneficiary, continue
paying a percentage of my retirement allowance to my beneficiary for life. If my
beneficiary predeceases me, change my allowance to the Single Life Allowance
(Option 0) amount and stop all payments at my death. I understand that I have up to
30 days after the last day of my retirement month to change my option or beneficiary.
(If you take this option, you must also check the percentage you wish to be continued
to your beneficiary.)
25% 50% 75%
If you elect the Single Life Allowance (Option 0) do not provide any beneficiary information.
If you wish to elect one of the other options, please read all of the information on this form and then complete the following section. Use
the beneficiary’s given name: Mary Smith, NOT Mrs. John Smith.
If you elect a Years Certain Option and wish to name more than one beneficiary, please let us know and we will provide you with an
appropriate form.
INFORMATION ABOUT YOUR OPTION BENEFICIARY: (Please print plainly or type)
Beneficiary’s Name: (First Middle Initial, Last) Beneficiary’s Sex:
M F
Beneficiary’s Social Security Number:*
Beneficiary’s Address: (Including Street, City, State and Zip Code)
Beneficiary’s Date of Birth: Relationship of Beneficiary to you:
*Social Security Number required (See statement below)
Please sign your
name in full
below:
I certify that the information on my application is true and complete to the best of my knowledge. I further certify that I am aware that
any false statement I knowingly make or permit to be made on this or any record of the Retirement System constitutes a crime
punishable by potential incarceration and other sanctions.
Retiree’s
Signature:__________________________________________________ Date:__________________________________
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 affix
stamp)
Electing An Option: The option you elect is important to both you and your beneficiary. Be sure you understand the nature of each
option, and elect the one that best fulfills your needs. Also, be sure you have checked the proper box for the option that you wish to elect.
On this form, you are selecting a method of payment. When you have completed this form and have had it notarized, the original should
be returned to: New York State and Local Retirement System, 110 State Street, Albany, New York 12244-0001
We will acknowledge receipt of the option selection by sending you a letter.
Designating a Beneficiary: Only one beneficiary may be named in a Joint Allowance or Pop-Up option. Under these options, proof of your
beneficiary’s date of birth must be submitted. If you wish to elect one of the Year Certain Options, you may designate more than one
beneficiary. If you wish to do so, please notify the Retirement System so we may send you the proper form for completion. If you elect one
of the Year Certain Options, you may designate your Estate as beneficiary. Under these options, you may change your beneficiary at any
time. For each change of beneficiary(ies), you must submit a form, which can be obtained from the Retirement System.
Information Services: Information Representatives are available at consultation sites throughout New York State. To find the one nearest
you, visit our website at www.osc.state.ny.us/retire. You can also contact our Call Center toll-free at 1-866-805-0990 or 518-474-7736 in
the Albany, New York area.
*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, 34, 311 and 334 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.
RS 6399 (Rev. 12/18) (Page 2 of 2)
