1. Employees’ Retirement System
  2. Membership Registration
  3. RS 5420
Employees’ Retirement System

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Membership Registration

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RS 5420
(Rev. 5/12)
Receipt Stamp
For OSC use only
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
If your employment is on a part-time, temporary or provisional basis, or less than 12 months per year, membership is optional.
IF YOUR MEMBERSHIP IS OPTIONAL, DO NOT COMPLETE OR SUBMIT THIS FORM UNLESS YOU DESIRE TO BECOME A MEMBER.
Instructions:
Please print clearly in ink or type.
Application must be signed and notarized on last page.
Employee:
Complete items 1–3, 10–13 on page 2 and other applicable sections.
Employer:
Complete items 4–9a.
FOR A REGISTRATION NUMBER:
Call 1-866-805-0990 or (518) 474-3081. Or fax the application to (518) 486-4382.
This completed membership application must be mailed to the Retirement System for the membership to be effective.
IMPORTANT INFORMATION:
Has this person been registered to membership by means of the telephone or
fax registration system?
㼀
Yes
㼀
No (If yes, enter the information given to you in the boxes below.)
In order to complete the registration process this membership registration form must be received by the Retirement System.
Location Code
Plan
Code
Group
Code
Date of
Membership
Mo.
Day
Year
Arrears
Code
Registration Number
Rate
To Be Completed by Employee
(Also see reverse side)
1
Employee’s Name
Last
First
Middle Initial
2
Employee’s Address
Street and/or PO Box #
City
State Zip Code + 4
3
Date of Birth
Month Day
Year
Sex
M F
㼀㼀
*Social Security Number
* NOTE: 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,
and 34 of the Retirement and Social Security Law. Your number will be used in identifying your retirement records and in the administration of the Retirement System.
Maiden or Other Name Used
_
To Be Completed by Present Employer
4
Employer Name
(Indicate State, or, if not, name of public entity by which employed and Department, Division, or Institution)
㼀
㼀㼀
(
)
㼀
_______________
_______________ _______________
_____________
________________
______________________________
(
)
_
5
Employer’s Address
Street
City
County
State
Zip Code + 4
Employer Telephone Number
6
Payroll Title:
Indicate Length of Work Year
10 Months
12 Months
Seasonal
Employer Fax Number
Check if Either Applies
Appointed Official
Elected Official
㼀
*If accountant, auditor, physician, attorney, engineer or architect please submit documentation as indicated
at www.osc.state.ny.us/retire/employers/classify_an_employee. htm
7
Enter the Date or Dates Relating to Employee’s Present Position
:
Part-Time Employment
Date of First Appointment
Month
Day
Year
Date of Permanent Appointment
Month
Day
Year
Full-Time Employment
Date of Temporary or
Provisional Appointment
Month
Day
Year
Date of Permanent or
Probationary Appointment
Month
Day
Year
8
Frequency of Payment:
Annually
㼀
㼀Semi-Annually
㼀Quarterly
㼀Monthly
Semi-Monthly
㼀
㼀Bi-weekly
㼀Weekly
Other – Please Specify
㼀
________________________________
9
Basis of Compensation and Rate (Tier 1, 2, 3, 4 and 5 ONLY):
Annual $
Daily $
Hourly $
Units of Work Performed $
per
(Example: $50 per meeting or $10 per examination, etc.)
9a
Basis of Compensation and Rate (Tier 6 ONLY):
Annual Wage $
Tier 6 requires employers to determine the Annual Wage for individuals who work
Part Time, Seasonal or on an Hourly, Daily or Unit of Work Basis. See the Chart on
Page Two for instructions.
Examples of Tier 6 annual wage for individuals paid at an Hourly, Daily or Unit of Work basis of compensation:
Hourly Employees
12 month Employee: $___________
Hourly
Rate
x ___________
Standard
Workday*
x 260
Days
Worked
= $
____________
Annual Wage
10 month Employee: $
___________
Hourly
Rate
x ___________
Standard
Workday*
x 180
Days
Worked
= $____________
Annual Wage
* Standard Workday (Hrs/day) (Applies to all Tiers): The minimum number of hours that can be established for a standard workday is six, while the maximum is
eight. A standard workday is the denominator to be used for the days worked calculation; it is not necessarily the number of hours the person actually worked.
For example, if a bus driver works four hours a day, you must still establish a standard workday between six and eight hours as the denominator for their days
worked calculation.
Daily Employees
12 month Employee: $_______________
Daily Rate
x 260
Days
Worked
= $
_______________
Annual Wage
10 month Employee: $_______________
Daily Rate
x 180
Days
Worked
= $_______________
Annual Wage
Unit of Work Employees
$_______________
Unit Rate
x _______________
# of Events**
** Estimated or Actual
= $__________________
Annual Wage
Example: Paid $50 per Meeting
_______________
Unit Rate
$
50
x _______________
# of Events***
*** An estimate of the number of events is acceptable
12 Meetings
=
Annual Wage
$__________________600
Note:
Any questions regarding annual wage, please contact the Retirement System.
To Be Completed by the Employee
10
Are you currently an
active
or
vested
member of
any other
public retirement system in New York State?
㼀
YES
㼀
NO
If yes, what is the name of the system?
REGISTRATION NUMBER (If Known)?
WARNING:
If you are now an active or vested member of any other public retirement system in New York State, you should contact that system concerning
the advantages of transferring your membership to this System. Failure to contact that system could cause loss of the privilege of transferring membership
and may effect contribution cessation dates.
11
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?
㼀
YES
㼀
NO
REGISTRATION NUMBER (If Known)?
12
Have you ever been a member of the New York State Employees’ Retirement System?
㼀
YES
㼀
NO
REGISTRATION NUMBER (If Known)?
13
List below all previous periods of employment with New York State or any New York State public entity (County, City, Town, Village, School District, Public
Authority or Special District). Include any military service. Attach additional sheets as required.
Name of Employer
Name of Dept.
or Agency
Title of
Position
From
Mo.
Day Year
To
Mo. Day Year
Indicate If Permanent
or Temporary, and
Full or Part Time
NOTE:
In accordance with the Personal Privacy Protection 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 benefits. Failure to provide information may result
in the failure to pay benefits. The System may provide certain information to participating employers. The official responsible for maintaining these records
is the Director of Member Services, New York State and Local Retirement System, Albany, NY 12244-0145; telephone number (518) 474-3524.
RS 5420 (Rev. 5/12) Page 2 of 4
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0.00
0.00
0.00
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Reinstatement to a former membership in accordance with Section 645 (Tiers 3, 4, 5 and 6).
Note: Completion of this form does not constitute an application for reinstatement.
Section 645 of the Retirement and Social Security Law allows members of a New York State public retirement system, whose original
membership was terminated or withdrawn, to return to their former Tier or date of membership.
Members with a former Tier 3, 4, 5 or 6 membership in the New York State and Local Employees’ Retirement System will be automatically
provided with the cost, if any, and procedures for reinstatement at a later date.
Former Tier 3, 4, 5 or 6 members of any NYS public retirement system,
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complete the section below
. We will provide you with the cost, if any, and procedures for reinstatement at a later date.
Reinstatement to a former membership in accordance with Section 645 (Tiers 1 and 2).
Members with a former Tier 1 or 2 membership in any New York public retirement system may apply for reinstatement by completing the
section below.
Important Information:
If you are not sure of your employer’s current Tier 1 or 2 retirement plan, or if you are a member of the Police and Fire Retirement System
or if you have any questions regarding reinstatement you should contact the Retirement System before completing the section below.
If you are given Tier 1 or 2 status, your Tier 3, 4, 5 or 6 contributions are
not refundable
and you will not be able to take a loan against
these contributions.
If your date of membership will be before April 1, 1960, you may owe contributions for services rendered prior to April 1, 1960. Any deficit
in contributions for service before the date noted will result in a reduction of your retirement benefit.
FORMER MEMBERSHIP INFORMATION:
PLEASE CHECK THE FIRST FORMER RETIREMENT SYSTEM YOU WERE A MEMBER OF:
㼀
New York State Teachers’ Retirement System
㼀
New York City Board of Education Retirement System
㼀
New York State and Local Employees’ Retirement System
㼀
New York City Teachers’ Retirement System
㼀
New York State and Local Police and Fire Retirement System
㼀 㼀
New York City Police Pension Fund
㼀
New York City Employees’ Retirement System
㼀
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
㼀
No
㼀
If Yes, what retirement system?______________________________________________________________________________
Are you receiving or eligible to receive a retirement benefit based on this service?
Yes
㼀
No
㼀
Signature __________________________________________________________
Date _________________________________
If you are eligible for a refund of contributions, the Retirement System is required to withhold 10% of the taxable amount of the refund for
federal taxes unless you instruct us not to take the withholding.
If you do not want the Retirement System to withhold federal income tax from your payment, sign and date this election.
I DO NOT WANT TO HAVE FEDERAL INCOME TAX WITHHELD FROM MY PAYMENT.
Signed:_______________________________________________________________ Date: _________________________________
RS 5420 (Rev. 5/12) Page 3 of 4
RS 5420 (Rev. 5/12) Page 4 of 4
Important:
If you find this form is not suited for the type of Designation
you prefer, please advise the Retirement System. In the meantime, for your
protection and the protection of your beneficiary(ies), you should make an
interim designation using this form. Beneficiaries’ complete name, address,
date of birth and relationship must be provided. Do not designate yourself. If
additional space is needed you may enter two names on a line.
This is a legal
document and, therefore, this form must not be altered.
To the Comptroller of the State of New York.
Designation of Primary Beneficiary(ies)
I hereby name the following as beneficiary(ies) to receive any death benefit
payable on my behalf. I realize that if a death benefit is payable for which the
beneficiaries are mandated by law, this designation will be superseded. If I
have named more than one beneficiary, it is my intention that those living at
the time of my death should share equally any benefit payable. I reserve the
right to change the designation at any time.
Name
㼀Male
Female
㼀
Birth Date
Relationship (Check one)
㼀
Spouse
㼀Parent
㼀
Child
㼀
Other
Address
Name
㼀Male
㼀
Female
Birth Date
Relationship (Check one)
㼀
Spouse
㼀Parent 㼀
Child
㼀
Other
Address
Name
㼀Male
㼀
Female
Birth Date
Relationship (Check one)
㼀
Spouse
㼀Parent 㼀
Child
㼀
Other
Address
Name
㼀Male
㼀
Female
Birth Date
Relationship (Check one)
㼀
Spouse
㼀
Parent
㼀
Child
㼀
Other
Address
Designation of Contingent Beneficiary(ies)
If all the above named beneficiaries die before I do, any benefits payable on
my behalf shall be paid to the following. I realize that, if a death benefit is
payable for which the beneficiaries are mandated by law, this designation will
be superseded. If I have named more than one beneficiary, it is my intention
that those living at the time of my death should share equally any benefit
payable. Furthermore, if I should out-live all these beneficiaries, any benefit
payable should be paid to my estate or any other beneficiary I name hereafter.
I reserve the right to change the designation at any time.
Name
㼀Male
㼀
Female
Birth Date
Relationship (Check one)
㼀
Spouse
㼀
Parent
㼀
Child
㼀
Other
Address
Name
㼀Male
㼀
Female
Birth Date
Relationship (Check one)
㼀
Spouse
㼀
Parent
㼀
Child
㼀
Other
Address
Name
㼀Male
㼀
Female
Birth Date
Relationship (Check one)
㼀
Spouse
㼀Parent 㼀
Child
㼀
Other
Address
Name
㼀
Female
㼀
Male
Birth Date
Relationship (Check one)
㼀Spouse 㼀Parent 㼀
Child
㼀
Other
Address
WARNING: If you are receiving a pension from a public retirement system in New York State, contact the system providing your pension BEFORE
signing this form. Failure to do so could result in the suspension of payment of your pension benefit.
IMPORTANT: You must sign and enter date below to affirm
Retirement System membership, and beneficiary designation.
I have made my Designation of Beneficiary as shown above and
acknowledge that my membership in the New York State and Local
Employees’ Retirement System is governed by the provisions of Article
15 of the Retirement and Social Security Law and that I am entitled
to all the benefits thereof. I understand that, as required by law, a
deduction will be made from my salary or compensation for retirement
contributions.
Signature
Date
Employee Telephone Number*
Employee E-Mail Address*
* Not Required
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 instru-
ment, the individual(s), or the person upon behalf of which the individual(s)
acted, executed the instrument.
NOTARY PUBLIC (Please sign and affix stamp)
Notary Stamp
FOR OFFICE USE ONLY
Reviewed
Examined

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