Form Ppf 35 - Buyback: Prior Nys/nyc Service - 2000
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1New York City Police Pension Fund
Control number:
NR
233 Broadway, 25th fl.
____________
New York, NY 10279-2501
Tier 2
Buyback: Prior NYS/NYC Service -- Chapter 552 of the Laws of 2000
Tier 3
1) Complete, sign and date Section A; 2) Send or deliver this form to your former
:
Member instructions
NY State or NY City agency employer, and request that they provide the information specified in Section B.
A. Member information (please print):
____________________________________
Command:
First name: __________________________ MI: ____ Last name: ____________________________________ Tax ID #: ______________
Address: __________________________________________ City: __________________________ State ____ Zip code: _____________
Email: ___________________________________________________ Cell/daytime phone: (_________)__________________________
:
____/____/_____ SSN: ______-____-_________ Prior agency: ______________________________________________
Date of birth
Prior agency start: ___ /____/______ Prior agency end:____/____/______ Prior job title: ______________________________________
Member signature: _________________________________________ Date*
:
_____/______/_________
B. Employment verification/certification: [Completed by the member's prior NYS or NYC employer]
The NYCPPF requires the following information pertaining to the above individual in order to verify his/her prior New York
agency employment in conjunction with this buyback of service request.
Please enclose the Personnel Record Card(s) and
payroll data (Form W-2 and/or Form 1099 desirable) that verify the information provided.
Mail the completed form and
supporting documentation to the NYCPPF at address at the top of this page. For any questions, contact the Membership
Services buyback staff at (212) 693-6860.
*
*
Job title: _____________________________________ Appointment date
: _____/_____/______ Resignation
: ____ /_____/_______
**
:
Agency name: ________________________________________ Retirement system
______________________________________
▼
1)
Gross earnings, contracted salaries, and hours worked are needed for full-time AND part-time employees.
$ Actual gross
$ Contracted
# Hours
earnings
worked
Break in service /absence without pay
Type of leave
Year
salary
*
________
From ____/_____/_______ To ____/_____/_______ _______________________________
______
_____________
______________
________
From ____/_____/_______ To ____/_____/_______ ________________________________
_____________ ______________
________
From ____/_____/_______ To ____/_____/_______ _______________________________
______
______________
________
From ____/_____/_______ To ____/_____/_______ _______________________________
______
_____________
______
_____________
______________
________
From ____/_____/_______ To ____/_____/_______ _______________________________
2) Agency certification:
I hereby state the information provided above is accurate. [Please print]
*
Full name
Signature:
Date
: _____________________________________
____________________________________
:_____/_____/_______
Title: _______________________________________ Agency name: ________________________________________________________
Agency address: ____________________________________________________________________
City: ___________________________________________ State: _____ Zip code:
_________________
Phone number:
FAX number
(_______)_________________
: (_______)______________________
**
Agency seal or stamp
*
1 of 1
PPF 35
mm/dd/yyyy
If applicable
1 /2013
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