Form Rs 5120 - Monthly Salary And Service Certification

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Monthly Salary and
Service Certification
Office of the New York State Comptroller
RS 5120
New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
(Rev. 11/11)
110 State Street, Albany, New York 12244-0001
User Name:
Date:
Unit:
Member’s Name ________________________________________________
Other Name(s) Known by _________________________________________
_____________________________________________________________
Registration Number ____________________________________________
PLEASE COMPLETE AND
Social Security Number __________________________________________
RETURN BY:
_________________________
Payroll Title & Department ________________________________________
Location Code
_____________________________
Claimed Periods of Employment ___________________________________
The above named member of this Retirement
Please indicate the established standard work day
System has claimed previous employment with
for this payroll title: (enter no. of hours per day in the box)
your agency or was not reported during the
Reminder: 6 Hours is the minimum and 8 hours is the
period(s) indicated. A certification of salary and
maximum standard work day allowable for Tier 2, 3, 4 & 5
service is required so we can determine the
amount of service credit this person may be
entitled to receive.
First day worked _______________________
£
Last day worked _______________________ or
still working
School Employees Only – Please indicate if
employee is a 10 or 12 month employee:
If you have any questions please contact us at 1-866-805-0990 or 518-474-7736.
or refer to the Employer Guide on our web site at:
£
£
10
12
University and Community College Employers:
Was this employee a member of the Optional Retirement Program, TIAA/CREF?
£
£
Yes
No
If YES, what was the employee’s first date of participation in the Optional Retirement Program? ____________________________
PLEASE COMPLETE ALL INFORMATION IN INK
I hereby certify that the information provided is correct.*
(Please note, the certification cannot be accepted if signed by the member for whom the information is being provided.)
___________________________________________________
__________________________________________________
Authorized Signature & Date
Authorizer, Please Print Name
___________________________________________________
__________________________________________________
Department & Title
Telephone Number & Fax Number
DO NOT SUBMIT AN ADJUSTMENT FORM FOR THE INFORMATION PROVIDED ON THIS FORM
* Please See Reverse

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