Form Ppf 170 - Option And Beneficiary Selection Form

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New York City Police Pension Fund
th
233 Broadway, 25
fl.
New York, NY 10279
(212) 693-6888
Option and Beneficiary Selection Form
First name: ________________________ MI: ____ Last name: ________________________________
Home address: ________________________________________________________________________
City: __________________________________________ State: ______ Zip code: ________________
Tax ID #: ________________ Pension #: ________________ Phone #: (_______)__________________
A. Directions:
1. Check one box in Section B to select it, and print your final selection on the line below Option 6.
2. If you choose Maximum Retirement Allowance, return page 1 only.
3. If you choose an Option, complete page 1 and page 2 and return both pages to NYCPPF.
it:
B. Mark one box below to select
Maximum Retirement Allowance
Option 1 – Return of Pension Reserve (Tier 1 members only)
Option 2 – 100% Joint and Survivor
Option 3 – 50% Joint and Survivor
Option 4 – Lump Sum: $ _______________ (if chosen, specify lump sum amount here)
Option 4 – Annuity: $ ________________ (if chosen, specify annuity amount here)
Option 4 – 2: 100% Joint and Survivor with Pop-up
Option 4 – 3: 50% Joint and Survivor with Pop-up
Option 4 – 4: Annuity with Pop-up: $ _____________ (if chosen, specify annuity amount here)
Option 5: 5-Year Certain
Option 6: 10-Year Certain
Print final selection (required): ________________________________________________
Signature: ____________________________________________ Date: ____/____/_______
Notarization:
[Notarization required if this form is mailed to NYCPPF]
State of __________ County of _______________________
On this _____ day of ___________________, 20 ___ before me
Personally appeared ____________________________________ ,
to me known and known to me to be the same person described herein
and who executed the foregoing instrument, and (s)he duly acknowledged
that (s)he executed the same.
Notary Public signature: ________________________________
Please affix stamp or seal
Pension Payroll
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PPF 170

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