Form Rs 6221 - Statement Of Accrued Payments And Leave Credits
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1
2STATEMENT OF ACCRUED
Office of the Ne w York State Comptroller
New York State and Local Retirement System
PAYMENTS AND LEAVE CREDITS
Employees’ Retirement System
Police and Fire Retirement System
RS 6221
110 State Street, Albany, New York 12244-0001
Phone: 1-866-805-0990 or 518-474-7736
Fax: 518-402-4433
(Rev. 7/09)
E-mail: nyslrsinfo@osc.state.ny.us
Web:
EMPLOYER NAME
AND ADDRESS
In reply refer to
Reg. No:
S. S. No:
Unit:
Re:
User ID:
Ret. Date:
Location Code:
THE INFORMATION REQUESTED BELOW IS NEEDED TO ACCURATELY CALCULATE THE RETIREMENT BENEFIT
OF THE ABOVE NAMED MEMBER. NO RETIREMENT BENEFITS WILL BE PAID TO THE EMPLOYEE LISTED ABOVE
UNTIL THIS FORM IS COMPLETED AND RETURNED TO THE ABOVE ADDRESS. PLEASE DO NOT FORGET TO SIGN
AND DATE THE BACK OF THE FORM.
THIS MEMBER WAS LAST REPORTED TO THE RETIREMENT SYSTEM ______________________________.
1. THE LAST DAY OF PAID SERVICE WAS ___________________________.
2.
THE TOTAL NUMBER OF UNUSED SICK LEAVE DAYS CREDITED TO THE ABOVE NAMED EMPLOYEE AT
RETIREMENT IS _____________ DAYS. (ENTER IN DAYS NOT HOURS)
SICK LEAVE DAYS FOR WHICH A LUMP SUM PAYMENT WAS MADE SHOULD NOT BE INCLUDED (ENTER 0 IF
NONE, ENTER UNKNOWN IF NOT KNOWN), ENTRY MUST BE MADE.
3.
PLEASE ENTER THE AMOUNTS PAID AND PERIODS COVERED BY THE FINAL FIVE SALARY PAYMENTS
(EXCLUDING ANY LUMP SUM PAYMENTS LISTED IN SECTION 5).
PERIOD ENDING
________________
GROSS SALARY $
________________
DATE PAID
________________
PERIOD ENDING
________________
GROSS SALARY $
________________
DATE PAID
________________
PERIOD ENDING
________________
GROSS SALARY $
________________
DATE PAID
________________
PERIOD ENDING
________________
GROSS SALARY $
________________
DATE PAID
________________
PERIOD ENDING
________________
GROSS SALARY $
________________
DATE PAID
________________
4. PLEASE INDICATE IF SALARY HAS BEEN INCREASED OR ANY SPECIAL PAYMENT IN ANTICIPATION OF,
OR BECAUSE OF RETIREMENT (OTHER THAN AS LISTED ABOVE - example termination pay).
IF YES, EXPLAIN
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
PLEASE COMPLETE BOTH SIDES OF THIS FORM IN ITS ENTIRETY AND SIGN
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