Form Rs 5420 - Employees' Retirement System Membership Registration

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Employees’ Retirement System
Office of the New York State Comptroller
Membership Registration
New York State and Local Retirement System
RS 5420
110 State Street, Albany, New York 12244-0001
(Rev. 5/16)
I f 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.
Receipt Stamp
Employee: Complete items 1–3, 10–13 on page 2 and other applicable sections. Employer: Complete items 4–9a.
For OSC use only
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?
Yes
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.
Report
Plan
Group
Date of
Location Code
Tier
Registration Number
Rate
Code
Code
Code
Membership
_
Mo.
Day
Year
Employee’s Name
Last
First
Middle Initial
1
Employee’s Address
Street and/or PO Box #
City
State
Zip Code + 4
_
2
3
*Social Security Number
Maiden or Other Name Used
Date of Birth
Sex
Month
Day
Year
M F
 
*
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.
Employer Name
(Indicate State, or, if not, name of public entity by which employed and Department, Division, or Institution)
4
Employer’s Address
Street
City
County
State
Zip Code + 4
Employer Telephone Number
_
5
(
)
Payroll Title:
Indicate Length of Work Year
Employer Fax Number
6
10 Months
12 Months
Seasonal
(
)
Check if Either Applies
*If accountant, auditor, physician, attorney, engineer or architect please submit documentation as indicated
Appointed Official
Elected Offi cial
at
Enter the Date or Dates Relating to Employee’s Present Position:
7
Part-Time Employment
Full-Time Employment
Date of Temporary or
Date of Permanent or
Date of First Appointment
Date of Permanent Appointment
Provisional Appointment
Probationary Appointment
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Frequency of Payment:
8
Annually
Semi-Annually
Quarterly
Monthly
Semi-Monthly
Bi-weekly
Weekly
Other – Please Specify
_____________________________
Basis of Compensation and Rate (Tier 1, 2, 3, 4 and 5 ONLY):
9
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
9a
Part Time, Seasonal or on an Hourly, Daily or Unit of Work Basis. See the Chart on
Annual Wage $______________________________
Page Two for instructions.

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