8. Tier Reinstatement Continued:
Former Membership Information: Please check the first Retirement System you were a member of:
New York State Teachers’ Retirement System
New York City Board of Education Retirement System
New York State and Local Employees’ Retirement System New York City Teachers’ Retirement System
New York State and Local Police and Fire Retirement System New York Police Pension Fund
New York City Employees’ Retirement System New York City Fire Pension Fund
PLEASE COMPLETE THE FOLLOWING (if known):
Former Registration Number: __________________________________ Date of Membership:________________________________
Former Name (if applicable): ____________________________________________________________________________________
Have you received credit for this former membership in any other retirement system? Yes No
If Yes, what Retirement System? _________________________________________________________________________________
Are you receiving or eligible to receive a retirement allowance based on this service? Yes No
9. Other Public Retirement System Memberships:
• Are you currently a member of another public Retirement System in New York State? Yes No
• Are you receiving or are you about to begin receiving a retirement benefit from any Retirement System on the basis of employment
with New York State or any public entity in the State? Yes No
• If yes, what Retirement System? ________________________________________ Registration Number: ____________________
10. Domestic Relations Order (DRO):
Retirement benefits are considered marital property and can be divided between you and your ex-spouse when the marriage ends in
divorce. Any division of your benefits must be stated in the form of a Domestic Relations Order (DRO) – a legal document that gives
us specific instructions on how your benefits should be divided.
• Do you have a current or pending legal restriction on the distribution of your pension benefit as a result of a DRO? Yes
No
• Have you ever been divorced? Yes No
11. Beneficiary/Option Information for Estimate:
This is not the document on which you designate a beneficiary under your retirement option. You are required to make your
option beneficiary on a separate form, called a “Retirement Option Election Form”. If you have not filed a Retirement
Option Election Form, we will be sending you one to complete and return. We are asking
the following information about your
intended beneficiary for informational purposes. It will ensure that the estimate, upon which you make your options selection, is
based on the correct beneficiary. We are not permitted by law to accept untimely option election forms. If your form is not timely filed,
the Law requires an option which does not provide benefits to any beneficiary.
Estimate Beneficiary Information:
Beneficiary Name Date of Birth Gender (M/F) Spouse (Y/N)
Item numbers 12 and 13 MUST be completed or your application will not be accepted.
12. Please sign your name in full below: Women should sign their own names, e.g. Jane Smith NOT Mrs. John Smith
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.
I hereby make application for Service Retirement. I understand that this application may not be withdrawn on or after the effective date of
retirement.
Signature:_____________________________________________
13. 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)
POST RETIREMENT EMPLOYMENT: Your paid public employment must cease at the time of your retirement. There are laws governing employment after retirement, and if
you plan to be employed by or contract with a public employer, it is important for you to know about them. Failure to comply with these laws could result in the suspension or
diminishment of your retirement allowance or termination of your retirement and reinstatement in the Retirement System as a new member.
Public employment is employment by, or contract with, the State of New York, one of its political subdivisions (county, city, town village, school district) or some other public
agency, such as a public authority. Employment by any other public employer located outside of New York State, employment by the Federal Government, or private
employment, does not need any approval and will in no way affect the retirement allowance paid to you by this Retirement System. Any questions concerning this most
important matter should be directed to the New York State and Local Retirement System. By signing this application I hereby elect coverage under Section 212 of the
Retirement and Social Security Law, which permits me to earn from post-retirement public service annual amounts which do not exceed the limit provided in such section,
without a resulting suspension or reduction of my retirement allowance.
HEALTH INSURANCE INFORMATION: The Retirement System does not administer Health Insurance Benefits. Any questions regarding this issue should be directed to your
last employer.
*Social Security Disclosure Re
quirement: 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 6037 (Rev. 09/18) (Page 2 of 2)
