Form Pf 5117 - Election Form For 20 Year Retirement Plan 384-D
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1Election Form for
20 Year Retirement Plan
384-d
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
PF 5117
110 State Street, Albany, New York 12244-0001
(Rev. 10/11)
TO THE COMPTROLLER OF THE STATE OF NEW YORK:
I hereby elect membership under the provisions of Section 384-d of
Registration No.
_______________________________________
the Retirement and Social Security Law which permits retirement
upon completion of 20 years of creditable service as an officer or
member of an organized Fire Department or organized Police Force
Social Security No.*
____________________________________
or Police Department of any County, City, Town, Village, Fire District
or Police District. I also hereby withdraw any previous election
including any under the provisions of Sec. 84 or Sec. 384.
Location Code No.
_____________________________________
Mailing Address (Please Print)
Employer ____________________________________________
Indicate County, City, Town, Village, etc.
Department __________________________________________
Name ______________________________________________
Payroll Title __________________________________________
Address _____________________________________________
__ _____________________________________________
Date of Appointment to Above Title:
_______/_______/______
City
State
Zip Code+4
Signature ____________________________________________
Acknowledgement
This election to be completed only by firemen, policemen or officers of
Fire Departments or Police Departments. It must be filed within one
year after becoming an officer or member, or within one year after the
State of ___________________
employer assumes all or part of the additional cost. A member who
adopts a benefit pursuant to this section may withdraw it only after it
County of ______________________
has been filed for at least one year.
On the ___ day of ____________ in the year _______ before me, the
IMPORTANT NOTICE: Every member participating on the basis of
this section shall be separated from the service on the last day of the
undersigned, personally appeared __________________________,
calendar month next succeeding the calendar month in which he attains
age sixty-five.
personally known to me or proved to me on the basis of satisfactory
*In accordance with the Federal Privacy Act of 1974 you are hereby
evidence to be the individual(s) whose name(s) is (are) subscribed
advised that disclosure of your Social Security account number is
mandatory pursuant to Section 11, 34, 311, and 334 of the Retirement
to the within instrument and acknowledged to me that he/she/they
and Social Security Law. Your number will be used in identifying your
retirement records and in the administration for the Retirement System.
executed the same in his/her/their capacity(ies), and that by his/her/
In accordance with with the Personal Privacy Law you are hereby
their signature(s) on the instrument, the individual(s), or the person
advised that pursuant to the Retirement and Social Security Law, the
Retirement System is required to maintain records. The records are
upon behalf of which the individual(s) acted, executed the instrument.
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
_______________________________
Services, New York State and Local Retirement Systems, Albany, NY
Notary Public
(Please sign and affix stamp)
12244; telephone number (518) 486-3134.
For Office Use Only
Rate ________________________________________________
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