Form Pf 5022 - Police And Fire Membership Application - New York State Comptroller - 2016
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1
2Office of the New York State Comptroller
Police and Fire Membership Application
PF 5022
New York State and Local Retirement System
(Rev. 6/16)
110 State Street, Albany, New York 12244-0001
Receipt Stamp
Instructions: Please print clearly in ink or type.
Employee: Complete items 1–3, 12–14 on page 2 and other applicable sections. This form no longer requires a signature for
membership purposes. Employer: Complete items 4–11a.
FOR A REGISTRATION NUMBER: Call 1-866-805-0990 or (518) 474-3081. Or fax the application to (518) 486-4382.
IMPORTANT INFORMATION: Has this person been registered to membership by means of the telephone or
fax registration system?
Yes
No
(If yes, enter the information given to you in the boxes below.)
Plan
Group
Date of
Tier
Location Code
DB
Registration Number
Rate
Code
Code
Membership
_
Mo.
Day
Year
Employee’s Name
Last
First
Middle Initial
1
Employee’s Address
Street, Apt. or Unit #, PO Box #
City
State
Zip Code + 4
_
2
3
Maiden or Other Name Used
Social Security Number*
Date of Birth
Sex
Month
Day
Year
M
F
* 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 311 and
334 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.
Employer Name
(Indicate State, or, if not, name of public entity by which employed and Department, Division or Institution) Employer Telephone Number
4
(
)
Employer’s Address (Include Street, City, County, State, Zip Code)
Employer Fax Number
5
(
)
Present Payroll Title:
Check if either applies:
6
Appointed Official
Elected Official
Enter the Information Relating to Employee’s Present Position:
7
Employment Status – Check each box that applies to this Employee’s position:
t
Date of First Employmen
Month
Day
Year
Temporary
Permanent
Part-Time
Provisional
Seasonal
Full-Time
8
Labor Contract Information
Is this member covered by an (existing) unexpired collective bargaining agreement that was in effect on January 9, 2010,
Yes
No
and was still in effect on the date of membership that requires you to offer a Special Plan Election?
If yes, please provide: Effective Date of Contract #_______________________
Termination Date of Contract #_______________________
Member’s Negotiating Unit/Labor Organization _________________________________________________________________
9
Contributory Status (you must check one):
Contributory
Non-Contributory
Frequency of Payment:
10
Annually
Semi-Annually
Quarterly
Monthly
Other –
Semi-Monthly
Bi-weekly
Weekly
Please Specify______________________________
Basis of Compensation and Rate (Tier 1, 2, 3 and 5 ONLY):
11
Annual $_______________
Daily $_______________ Hourly $_______________
Units of Work Performed $_____________ per _____________________
(Example: $50 per meeting or $10 per examination, etc.)
Basis of Compensation and Rate (Tier 6 ONLY):
Tier 6 requires employers to determine the Annual Wage for individuals who work Part Time,
11a
Seasonal or on an Hourly, Daily or Unit of Work Basis. See the Chart on Page Two for instructions.
Annual Wage $_________________________________
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