Form Rs 5509 - Application For Military Service Credit Under Article 20-Rssl
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1
2Application for Military Service Credit
Office of the New York State Comptroller
Under Article 20-RSSL
RS 5509
New York State and Local Retirement System
110 State Street, Albany, New York 12244-0001
(Rev. 6/16)
SEE IMPORTANT INFORMATION ON BACK OF FORM
PRINT USING ONLY BLUE OR BLACK INK AND ATTACH MILITARY DISCHARGE PAPERS (DD-214)
Name _____________________________________ Social Security Number ______ - ______ - _________
Address ____________________________________ Registration Number __________________________
City _______________________________________ State _____________ Zip Code ________________
(
)
(
)
Phone: Work:
________ –_______ – ______________ Phone: Home:
_
_____
__ –_______ – _____________
Do you have credit for ANY military service in another public retirement system in New York State?
Yes
No
If yes, indicate which system(s)
New York State Employees’ Retirement System
New York City Teachers’ Retirement System
New York State Police & Fire Retirement System
New York City Board of Ed. Retirement System
New York State Teachers’ Retirement System
New York City Police Pension Fund
New York City Employees’ Retirement System
New York City Fire Dept. Pension Fund
I ___________________________________________, request credit for this service as provided for in
Article 20 of the Retirement and Social Security Law. I understand that I will be provided with the cost for this
service and will receive credit only in proportion to the amount of that cost I pay to the Retirement System.
I have enclosed my DD-214 showing my dates of enlistment.
Signed _________________________________________
Date _____________
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