Form Rs 6047-N - World Trade Center Notice For Members And Retirees Of The New York State And Local Retirement System
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1
2World Trade Center Notice
RECEIVED
for Members and Retirees of
the New York State and
Offi ce of the New York State Comptroller
New York State and Local Retirement System
Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
RS 6047-N
(Rev. 3/15)
You must fi le this form with the New York State and Local Retirement System on or before September 11, 2015.
If you are permanently incapacitated or become permanently incapacitated in the future, you will also need to fi le the
Application for World Trade Center Accidental Disability Presumption (RS 6047-W) to receive the benefi t.
To be eligible for this presumption, the applicant must have participated in World Trade Center rescue,
recovery or clean up operations for any period of time within the fi rst 48 hours after the fi rst airplane crashed,
or a minimum of 40 hours between September 11, 2001 and September 12, 2002.
INFORMATION ABOUT YOU
1. NAME:
2. ADDRESS:
3. REGISTRATION, RETIREMENT, OR SOCIAL SECURITY
4. PHONE NUMBER:
NUMBER*:
5. JOB TITLE ON 9/11/2001:
6. EMPLOYER/ORGANIZATION 9/11/2001:
7. CURRENT JOB TITLE:
8. CURRENT EMPLOYER:
Locations
Dates
Name and Address of Employer/Organization** Under Which Work Was Performed
World Trade Center Site
Fresh Kills Landfi ll
New York City Morgue
Temporary Morgue on pier locations
on the west side of Manhattan
Barges between the west side
of Manhattan and the Fresh Kills
Landfi ll
If you worked at any sites not listed above, list the site with the address below.
Locations
Dates
Name and Address of Employer/Organization** Under Which Work Was Performed
Description of Duties performed during the WTC rescue and recovery or clean up operations
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