Adjustment Report
Office of the New York State Comptroller
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New York State and Local Retirement System
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Employees’ Retirement System
RS 2050
Police and Fire Retirement System
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110 State Street, Albany, New York 12244-0001
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(Rev. 1/14)
SEE INSTRUCTIONS FOR COMPLETING FORM ON BACK
DO NOT COMPLETE THIS FORM IF THIS INFORMATION HAS ALREADY BEEN SUBMITTED ON A SALARY AND SERVICE CERTIFICATION
Employer Name
Employer Code
Report Code
0
Page________of________
Retirement Registration
Member’s Name
Last 4 digits of
Report Period
Days
Days for Period
Salary
Salary for Period
Additional
Contributions For Period
Number
Last
First
M.I.
Social Security Number
Month/Year
Adjustment
Should Be
Adjustment
Should Be
Contribution Adj.
Should Be
I certify that the adustments on this form constitute a true, correct and complete accounting of all such adjustments.
TOTALS
They have not been and willl not be shown on any other report. I certify that each person actually worked the
adjusted number of days or was paid the adjusted amount of salary, and that this data was determined according
to Part 315 of Title 2 of the New York State Codes, Rules and Regulations.
Use these columns only if check is
enclosed
Certified By
Title
Date
Telephone Number
(
)
All changes to your monthly report (except reductions in contributions) must be done on this form. For adjustments to loans or arrears, please call 518-474-2987 for instructions.
RETIREMENT SYSTEM USE ONLY
Examined By
Date