Form Rs 6400 - Retirement Option Election Form For Tier 3, 4, 5 And 6 Ers Members

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Retirement Option Election Form

Office of the New York State Comptroller

New York State and Local Retirement System

For Tier 3, 4, 5 and 6 ERS Members

Employees’ Retirement System

Police and Fire Retirement System

For Designating Multiple Beneficiaries

110 State Street, Albany, New York 12244-0001

RS 6400

(Rev. 4/13)

MAKE NO ALTERATIONS TO THIS FORM. Please review carefully the options available and the instructions provided. You must 1) elect an

option by checking the appropriate box, 2) sign the completed form, 3) have it notarized, and 4) return it promptly.

IMPORTANT: You must file your Option Election form before your pension becomes payable, which is the first day of the month following

your retirement. You have up to 30 days after your pension benefit becomes payable to change your option selection. If your election is not

timely, by law, we must process your retirement as if you had selected the Single Life Allowance (Option 0).

INFORMATION ABOUT YOU

1. Name (First, Middle, Initial, Last)

3. Social Security Number*

2. Address

4. Registration Number

____________________________________________________________

5. Date of Birth

Month

Day

Year

____________________________________________________________

* Social Security Number required. (See statement on reverse side.)

To the Comptroller of the State of New York:

Five Year Certain

I elect to receive a reduced lifetime retirement allowance. If I die within five years after my



(Option 3)

retirement date, continue paying my retirement allowance for the remainder of the five years

to my beneficiary. If my beneficiary predeceases me, but I also die within five years following

006

my retirement, continue payments for the rest of the five year period to another beneficiary

I may name. If there is no surviving beneficiary, make a lump sum payment to my Estate.

If I die more than five years after my retirement date, stop all payments at my death.

Ten Year Certain

I elect to receive a reduced lifetime retirement allowance. If I die within ten years after my



(Option 4)

retirement date, continue paying my retirement allowance for the remainder of the ten years

to my beneficiary. If my beneficiary predeceases me, but I also die within ten years following

007

my retirement, continue payments for the rest of the ten year period to another beneficiary

I may name. If there is no surviving beneficiary, make a lump sum payment to my Estate.

If I die more than ten years after my retirement date, stop all payments at my death.

Electing an Option

The option you elect is important to both you and your beneficiary. Be sure you understand the nature of each option, and elect the one that best fulfills your

needs. Also, be sure that you have checked the proper box for the option that you wish to elect. On this form, you are selecting a method of payment. When

you have completed this form and have had it notarized, the original should be returned to: New York State and Local Retirement System, 110 State Street,

Albany, New York 12244. When your option form is received in this office, we will acknowledge receipt of the option by sending you a letter.

Designating a Beneficiary

If you elect one of the above Years Certain options, you may designate more than one beneficiary. Under these options, you may change your beneficiary at

any time. For each change of beneficiary(ies), you must submit a form which can be obtained from the Retirement System. If you wish to elect one of the Joint

Allowance or Pop-Up options, on which you may name only one beneficiary, you should request the proper option form immediately. If you wish to elect the

Single Life Allowance, which requires no beneficiary, you should request the proper form immediately.

Information Services

Information Representatives are available at 16 consultation sites throughout New York State. To find the one nearest you, visit our website at

ny.us/retire. You can also contact our Call Center toll-free at (866) 805-0990, or (518) 474-7736 in the Albany area.