OFFICE SERVICES ONLY

NET-2 (5/12)

NY

STRS

NEW YORK STATE TEACHERS’ RETIREMENT SYSTEM

10 Corporate Woods Drive, Albany, NY 12211-2395

APPLICATION FOR MEMBERSHIP

Please Provide All Requested Information

PART 1 — TO BE COMPLETED BY APPLICANT

Phone Number

()–

Date of Birth

//

Month

Day

Year

Gender

Male

Female

Marital Status (optional)

Married Single

Former Name

Last Name

(Refer to Section 1 of the NYSTRS Employer Manual at www.nystrs.org)

––

Social Security Number

Street Address

Street Address

City

Zip Code

–

State

Last Name

First Name

MI

1

First date of full-time service

OR

2

The earlier of:

First day of service, during or after

the month in which both

service was rendered and the

application was notarized.

(Service can be rendered after the

month of notarization.)

OR

First date of service for which

deductions began (

not payroll

date

).

//

Month

Day

Year

Mandatory Membership

Optional Membership

//

Month

Day

Year

//

Month

Day

Year

LOCATION CODE

DISTRICT NAME

PROJECTED EARNINGS 7/1-6/30

CURRENT YEAR

PROJECTED EARNINGS 7/1-6/30

NEXT YEAR

SIGNATURE OF AUTHORIZED OFFICIAL

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Yes No

Title

(Required)

:

____________________________________________________

---

* SIX IMPORTANT

QUESTIONS

CREDIT

*

As a member, you are responsible for ensuring your records are complete and accurate. Failure to provide any of the

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For an explanation of questions 1-5, see page 5.

- 2 -

PART 3 — TO BE COMPLETED BY APPLICANT

1.

Are you now a member of another New York State (NYS) or New York

YES

NO

City (NYC) public retirement system?

Name of Retirement System:

2.

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YES

NO

public retirement system?

Name of Retirement System:

Retirement Number:

3.

If you have

former membership service

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YES

NO

reinstated, do you elect reinstatement?

This election is irrevocable.

If yes, in what system was your former service credited:

Name of Retirement System:

System Membership or Registration #:

4.

Do you wish to claim previous NYS or NYC public employment or

YES

NO

public teaching service not included in question 3?

5.

Have you ever served in the armed forces of the United States?

YES

NO

6.

Are you currently rendering service at a NYS University or Community

YES

NO

College under the

Optional Retirement Program

?

If yes, name the college:

---

Please review all information on page 4 before completing this area.

Any changes made on this application

must

be initialed.

––

Member Social Security Number

Name and Address of Bene

À

ciary(ies)

PART 4 — DESIGNATION OF BENEFICIARY

( NET-11.4)

Name and Address of Bene

À

ciary(ies)

?

Continued on Back

?

Street Address

Street Address

Zip Code

–

State

City

Date of Birth

//

Month

Day

Year

––

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Relationship

Spouse

Child

Other

Male

Female

Last Name

First Name

MI

Check One:

Primary Contingent

- 3 -

Street Address

Street Address

Zip Code

–

State

City

Date of Birth

//

Month

Day

Year

––

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Male

Female

Last Name

First Name

MI

Check One:

Primary Contingent

Relationship

Spouse

Child

Other

---

I certify that the information I provide on this application is correct. I understand that I must contribute between 3% to 6%,

based on my earnings, if my death occurs prior to retirement or the termination of my membership, those contributions,

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updated based on the submission of payroll data by my employer.

This application must be signed and notarized in order to be valid.

Married women must use their given name (Mary Smith not Mrs. John Smith)

Signature of

Applicant

State of ___________________________________________

County of _________________________________________

On this ___________ day of ________________________________ in the year _____________ before me, the undersigned,

a Notary Public in and for said State, personally appeared ______________________________________________________,

personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is

subscribed to the within instrument, and acknowledged to me that he/she executed the same in his/her capacity,

and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual

acted, executed the instrument.

Signature of Notary:

____________________________________________________

Expiration Date:

________________________

㼀

I understand my designated bene

À

ciary(ies)

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ill receive the death bene

À

t coverage authori

]

ed by Paragraph 2 of Section 606(a)

of the Retirement and Social Security La

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.

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-

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for this coverage.

Name and Address of Bene

À

ciary(ies)

–

–

Member Social Security Number

- 6 -

Street Address

Street Address

Zip Code

–

State

City

Date of Birth

//

Month

Day

Year

––

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Male

Female

Last Name

First Name

MI

Check One:

Primary Contingent

Relationship

Spouse

Child

Other

---

As you complete this application, you are joining one of the largest public retirement systems in the United States.

The System makes every effort to provide its members with the best possible service. Once we receive your

membership application, we will send you an acknowledgement letter and a permanent membership card. To

learn more about your membership, we urge you to read

Your First Look at NYSTRS

and the

Active Members’

, which are available in the Library at www.nystrs.org. We welcome you to the ranks of the more than

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The New York State Teachers’ Retirement System is required by the Education Law, Retirement and Social Security

Law, and other laws to collect and maintain records containing personal information on its members. We collect

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are entitled. This information is disclosed only where authorized by state or federal law. Failure to provide all

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If you need assistance in completing Part 4

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of this application, please call (800) 348-7298, Ext. 6130.

DESIGNATION OF BENEFICIARY

㼀㼀

If you

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ish to name more than three bene

À

ciaries, please ask your school business of

À

ce for an additional

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(NET-11.4) form to complete and submit

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ith this application.

㼀㼀

If you

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ish to designate a custodian for a minor, a testamentary trust, an intervivos trust, or a corporation,

please contact us for instructions to properly complete the designation at (800) 348-7298, Ext. 6130.

㼀㼀

For each bene

À

ciary, be sure you have checked either primary or contingent.

㼀㼀

At least one bene

À

ciary must be designated as primary.

㼀㼀

Contingent bene

À

ciaries should be listed after the primary.

㼀㼀

Do not number bene

À

ciaries.

㼀㼀

List all requested information for each bene

À

ciary. For married

Z

omen, use their given name (Mary Smith

not Mrs. John Smith).

㼀㼀

An unborn child may not be named as a bene

À

ciary.

㼀㼀

If you

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ish to name your estate as bene

À

ciary, please

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rite

´

MY ESTATE

µ

on the bene

À

ciary name line. We

also suggest that you contact your tax advisor to determine if this designation is in your best interest.

㼀㼀

Percentage allocations for each category (primary or contingent) must equal 100

 

. Only

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hole number

percentage designations are allo

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ed.

㼀㼀

If your bene

À

ciary designation is deemed invalid,

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e

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ill update your bene

À

ciary as your estate until a valid

designation is

À

led.

DEATH BENEFIT ELECTION

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Retirement and Social Security Law.

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a year of member service, increasing each year to a maximum of three years’ salary after three or more years of

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- 4 -

---

QUESTION 1

If you have an active membership in one of the NYS public retirement systems shown below, you may be eligible to transfer that

membership to this System. A transfer will bring all of your service credit, member contributions (if any) and original date of mem-

bership to your new Teachers’ Retirement System membership.

Ne

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York State public retirement systems from

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hich a transfer of membership is possible:

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To request a transfer, please obtain forms and instructions from the appropriate retirement system(s) noted above.

QUESTION 2

If you are receiving a pension from any public NYS retirement system, we strongly urge you to contact that system to determine

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QUESTION 3

If you held a previous membership in a New York State or New York City public retirement system, you may be eligible for

reinstatement to an earlier date of membership. By answering

YES

to question 3, we will review your eligibility for reinstatement and

advise you accordingly. If you are reinstated to a Tier 1 or 2 membership, there will be no cost to you and you will no longer be

required to make member contributions. However, if you are reinstated to a Tier 3-5 membership, there is a cost associated with

the reinstatement. Once processing has been completed for your reinstatement to a Tier 3 or 4 membership, and if you meet the

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stop withholding effective

July 1 of the school year in

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hich your payment

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as received in the system

.

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10 years of service or 10 years of membership

.

Generally, it is to your advantage to be reinstated to an earlier date of membership.

Ho

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ever, there are situations

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here it may

not be in your best interest to elect reinstatement.

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details of your reinstatement with a System representative.

Note: By checking this box you are electing tier reinstatement. A tier reinstatement election is irrevocable.

QUESTION 4

You may be eligible to receive prior service credit for New York State public service (full-time, part-time, or substitute work),

including NYC, if such service was credited or would have been creditable in a New York State public retirement system. Visit our

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As a Tier 6 member, the following service is not creditable in our System:

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Out-of-state teaching service;

㼀

Service for private or parochial schools, for the federal government or in armed forces dependent schools; or,

㼀

Non-public service.

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Note: It is not necessary to check this box if all service

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as credited to a former membership AND you have elected tier rein-

statement by checking box 3.

QUESTION 5

To initiate your claim for military service with this System, you will need to submit a copy of Form DD-214, Armed Forces of the US

Report of Transfer or Discharge.

If you do not have the DD-214, you may be able to obtain it by contacting:

National Personnel Records Center

1 Archives Drive

St. Louis, Missouri 63138

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- 5 -