Form Rs 5497 - Election Form For Sheriffs, Undersheriffs, And Deputy Sheriffs 20 Year Retirement Plan Under Article 14-B

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Election Form for Sheriffs,

Undersheriffs, and Deputy Sheriffs

20 Year Retirement Plan

Office of the New York State Comptroller

Under Article 14-B

New York State and Local Retirement System

Employees’ Retirement System

Police and Fire Retirement System

RS 5497

110 State Street, Albany, New York 12244-0001

(Rev. 3/11)

This election to be completed only by Sheriffs, Undersheriffs, or Deputy Sheriffs directly engaged in criminal law

enforcement 50 percent or more of the time, who are police officers under the criminal procedure act, and who are

employed by a county which has elected to make these benefits available.

TO THE COMPTROLLER OF THE STATE OF NEW YORK:

I hereby elect to contribute under the provisions of Section 552 of Article 14-B of the Retirement and Social Security Law,

providing for retirement at one-half final average salary upon completion of 20 years of service. I understand that this

election must remain in effect for at least one year, and may not be withdrawn or modified during that one year period.

Employer _______________________________________

Registration No. _________________________________

Payroll Title _____________________________________

Last 4 Digits of Social Security Number* ______________

Name (Please Print) ______________________________

Address _______________________________________

Signature _______________________________________

City______________________ State_____ Zip ________

NOTE: This election is not effective until it is received by the Retirement System.

ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC

State of________________________________________

County of________

__________________________

On the____day of________ in the year_____ before me, the undersigned, personally appeared_______________________________,

personally known to me or proved to me on the basis of satisfactory 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 his/her/their capacity(ies), and

that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted,

executed the instrument.

NOTARY PUBLIC (Please sign and affix stamp)

SHERIFF’S CERTIFICATION FOR DEPUTY SHERIFFS:

I, ____________________________________________,

the sheriff of

________________________________________

county, do hereby certify that

_________________________________________,

is employed as a Deputy Sheriff under my

jurisdiction, that (s)he is engaged 50 percent or more of the time in criminal law enforcement activities, and is a police officer

under the criminal procedure act.

__________________________________

___________________________________________

DATE

SHERIFF

PERSONAL PRIVACY PROTECTION LAW

In accordance with the Personal Privacy Law you are hereby advised that pursuant to the Retirement and Social Security Law, the Retirement System is required to maintain

records. The records are necessary to determine eligibility for and to calculate benefits. Failure to provide information may result in the failure to pay benefits. The System may

provide certain information to participating employers. The official responsible for maintaining these records is the Director of Member and Employer Services, New York State

and Local Retirement Systems, Albany, NY 12244; telephone number (518) 474-3524.

*SOCIAL SECURITY DISCLOSURE REQUIREMENT

In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the Social Security Account Number is mandatory pursuant to Sections 11, 31, 34

and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of the Retirement System.