Form Rs 5420 - Employees' Retirement System Membership Registration Page 4
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4Name: _____________________________________________
If you have not already done so, please complete an RS5127 Designation of Beneficiary With Contingent Beneficiaries form to designate
beneficiary(ies) to receive an Ordinary Death Benefit. If there is no RS5127 Designation of Beneficiary With Contingent Benefi ciaries
form on file with this System, your Ordinary Death Benefit will become payable to your estate.
WARNING: If you are receiving a pension from a public retirement system in New York State, contact the system providing your pension BEFORE
signing this form. Failure to do so could result in the suspension of payment of your pension benefi t.
IMPORTANT: You must sign and enter date below to affirm
ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC
Retirement System membership.
State of_________________ County of ____________________________
I acknowledge that my membership in the New York State and Local
Employees’ Retirement System is governed by the provisions of Article
On the ____ day of ________ in the year ____ before me, the undersigned,
15 of the Retirement and Social Security Law and that I am entitled
personally appeared __________________________________________,
to all the benefits thereof. I understand that, as required by law, a
deduction will be made from my salary or compensation for retirement
personally known to me or proved to me on the basis of satisfactory
contributions.
evidence to be the individual(s) whose name(s) is (are) subscribed to the within
instrument and acknowledged to me that he/she/they executed the same in
Signature
his/her/their capacity(ies), and that by his/her/their signature(s) on the instru
ment, the individual(s), or the person upon behalf of which the individual(s)
acted, executed the instrument.
Date
Employee Telephone Number*
NOTARY PUBLIC (Please sign and affix stamp)
Notary Stamp
Employee E-Mail Address*
*Not Required
FOR OFFICE USE ONLY
Reviewed
Examined
RS 5420 (Rev. 5/16) Page 4 of 4
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