Form Pf 5022 - Police And Fire Membership Application - New York State Comptroller - 2016 Page 2
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2Name:________________________________________________________
If you have not already done so, please complete an RS5127 Designation of Benefi ciary With Contingent Beneficiaries form to
designate beneficiary(ies) to receive an Ordinary Death Benefit. If there is no RS5127 Designation of Benefi ciary With Contingent
Beneficiaries form on file with this System, your Ordinary Death Benefit will become payable to your estate.
Examples of Tier 6 annual wage for individuals paid at an Hourly, Daily or Unit of Work basis of compensation:
Hourly Employees
Daily Employees
0.00
0.00
12 month Employee:
$___________ x
___________ x 260
=
$____________
12 month Employee:
$______________ x 260
=
$______________
Hourly
Standard
Days
Annual Wage
Daily Rate
Days
Annual Wage
Rate
Workday*
Worked
Worked
0.00
0.00
10 month Employee:
$___________ x
___________ x 180
=
$____________
10 month Employee:
$______________ x 180
=
$______________
Hourly
Standard
Days
Annual Wage
Daily Rate
Days
Annual Wage
Rate
Workday*
Worked
Worked
* 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
works. For example, if a police officer 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.
Unit of Work Employees
Example: Paid $50 per Meeting
0.00
50
12
600
$_______________ x
_______________ =
$__________________
$
_______________ x
_______________ =
$
__________________
Unit Rate
# of Events**
Annual Wage
Unit Rate
# of Events***
Annual Wage
**Estimated or Actual
***An estimate of the number of events is acceptable
Are you currently an active or vested member of any other public retirement system in New York State?
YES
NO
If yes, what is the name of the system?
REGISTRATION NUMBER (If Known)?
12
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 the loss of the privilege of transferring membership
and may effect contribution cessation dates.
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
REGISTRATION NUMBER (If Known)?
13
Have you ever been a member of the New York State Police and Fire Retirement System?
YES
NO
REGISTRATION NUMBER (If Known)?
14
If you were previously a member of any public retirement system in New York State, you may be eligible for reinstatement to an earlier tier or date of
membership, however an earlier tier or date of membership does not always result in a better benefit. Warning: If you are not sure of your employer’s current
Tier 1 or 2 retirement plan, or if your date of membership in your former retirement system is between July 1, 2009 and January 8, 2010, you should contact
the Retirement System before completing the section below. To apply for tier reinstatement, please complete this section.
FORMER MEMBERSHIP INFORMATION:
PLEASE CHECK THE APPROPRIATE FIRST FORMER 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 City 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
Signature_______________________________________________________________________ (Required for Tier Reinstatement Request Only)
Date ______________________________________________
For Retirement System use only
Examined:____________________________________________
Reviewed:____________________________________________
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 Systems, Albany, NY 12244-0001; telephone number 1-866-805-0990.
PF 5022 (Rev. 6/16) Page 2
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