Form Rs 5420 - Employees' Retirement System Membership Registration Page 2
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4Name: _____________________________________________
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
10 month Employee: $_________
x __________
x 180
= $_______________
0.00
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 worked.
For example, if a bus driver 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 Meetings
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
Note: Any questions regarding annual wage, please contact the Retirement System.
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)?
10
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 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)?
11
Have you ever been a member of the New York State Employees’ Retirement System?
YES
NO
REGISTRATION NUMBER (If Known)?
12
List below all previous periods of employment with New York State or any New York State public entity (County, City, Town, Village, School District,
Public Authority or Special District). Include any military service. Attach additional sheets as required.
Indicate If Permanent
From
To
13
Name of Dept.
Title of
Name of Employer
or Temporary, and
or Agency
Position
Mo.
Day
Year
Mo.
Day Year
Full or Part Time
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 System, Albany, NY 12244-0145; telephone
number (518) 474-3524.
RS 5420 (Rev. 5/16) Page 2 of 4
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