Form Rs 5420 - Employees' Retirement System Membership Registration Page 3
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Name: _____________________________________________
Reinstatement to a former membership in accordance with Section 645 (Tiers 3, 4, 5 and 6).
Note: Completion of this form does not constitute an application for reinstatement.
Section 645 of the Retirement and Social Security Law allows members of a New York State public retirement system, whose original
membership was terminated or withdrawn, to return to their former Tier or date of membership.
Members with a former Tier 3, 4, 5 or 6 membership in the New York State and Local Employees’ Retirement System will be automatically
provided with the cost, if any, and procedures for reinstatement at a later date.
Former Tier 3, 4, 5 or 6 members of any NYS public retirement system, other than the NYS Employees’ Retirement System, please
complete the section below. We will provide you with the cost, if any, and procedures for reinstatement at a later date.
Reinstatement to a former membership in accordance with Section 645 (Tiers 1 and 2).
Members with a former Tier 1 or 2 membership in any New York public retirement system may apply for reinstatement by completing the
section below.
Important Information:
If you are not sure of your employer’s current Tier 1 or 2 retirement plan, or if you are a member of the Police and Fire Retirement System
or if you have any questions regarding reinstatement you should contact the Retirement System before completing the section below.
If you are given Tier 1 or 2 status, your Tier 3, 4, 5 or 6 contributions are not refundable and you will not be able to take a loan against
these contributions.
If your date of membership will be before April 1, 1960, you may owe contributions for services rendered prior to April 1, 1960. Any deficit
in contributions for service before the date noted will result in a reduction of your retirement benefit.
FORMER MEMBERSHIP INFORMATION:
PLEASE CHECK THE 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 benefit based on this ser vice?
Yes
No
Signature __________________________________________________________ Date _________________________________
If you are eligible for a refund of contributions, the Retirement System is required to withhold 10% of the taxable amount of the refund for
federal taxes unless you instruct us not to take the withholding.
If you do not want the Retirement System to withhold federal income tax from your payment, sign and date this election.
I DO NOT WANT TO HAVE FEDERAL INCOME TAX WITHHELD FROM MY PAYMENT.
Signed:_______________________________________________________________
Date: _________________________________
RS 5420 (Rev. 5/16) Page 3 of 4
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