Rs6047-N - World Trade Center Notice - Office Of The State Comptroller

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Office of the New York State Comptroller
World Trade Center Notice
RECEIVED
for Members and Retirees of
the New York State and
New York State and Local Retirement System
Local Retirement System
110 State Street, Albany, New York 12244-0001
RS 6047-N
(Rev. 9/16)
You must file this form with the New York State and Local Retirement System on or before September 11, 2018.
If you are permanently incapacitated or become permanently incapacitated in the future, you will also need to file the
Application for World Trade Center Accidental Disability Presumption (RS 6047-W) to receive the benefit.
To be eligible for this presumption, the applicant must have participated in World Trade Center rescue,
recovery or clean up operations for any period of time within the first 48 hours after the first airplane crashed,
or a minimum of 40 hours between September 11, 2001 and September 12, 2002.
INFORMATION ABOUT YOU
1. NAME:
2. SEX:
3. ADDRESS:
M
F
4. REGISTRATION NUMBER:
5. SOCIAL SECURITY NUMBER*:
or
RETIREMENT NUMBER, if retired:
XXX-XX-
7. DATE OF BIRTH:
6. TELEPHONE NUMBERS:
HOME (
)
WORK (
)
CELL (
)
/
/
8. JOB TITLE ON 9/11/2001:
9. EMPLOYER/ORGANIZATION 9/11/2001:
10. CURRENT JOB TITLE:
11. CURRENT EMPLOYER:
Locations
Dates
Name and Address of Employer/Organization** Under Which Work Was Performed
World Trade Center Site
Fresh Kills Landfill
New York City Morgue
Temporary Morgue on pier locations
on the west side of Manhattan
Barges between the west side
of Manhattan and the Fresh Kills
Landfill
If you worked at any sites not listed above, list the site with the address below.
Locations
Dates
Name and Address of Employer/Organization** Under Which Work Was Performed
Description of Duties performed during the WTC rescue and recovery or clean up operations

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