Form F399 - Affidavit Concerning Lost Check printable pdf download

NYCERS USE ONLY

F399

*399*

Mail completed form to:

30-30 47th Avenue, 10th Fl

Long Island City, NY 11101

Affidavit Concerning Lost Check

This form is for members and pensioners who wish to report the loss of a check. In order to report such a loss, you must fill out this

form and return it to NYCERS. Please be sure to read the instructions below and complete the requested information. NOTE: If the

address you provide on this form is different from your address in our system, the new address will become your official

address in our records. If you have any questions regarding this form, please contact our Call Center at 347-643-3000.

Member Number

Last 4 Digits of SSN

Home Phone Number

Work Phone Number

Pension Number

(

)

(

)

First Name

M.I.

Last Name

Address

Apt. Number

State

Zip Code

City

TYPE OF CHECK LOST (please check only one box from Section A or Section B):

Section A

Tier 1 or Tier 2 Loan

Monthly Pension Payment

Fractional Benefit

A replacement (paper check) will be sent to the mailing address on file if you checked a box in Section A. If you would like your

Monthly Pension Payment direct-deposited in the future, you must complete and submit Form 380, available at

--OR--

Section B

Tier 3, Tier 4 or Tier 6 Loan

Lump-Sum Survivor Benefit (Death in Service)

Refund (all tiers)

Lump-Sum Pensioner Survivor Benefit

If you checked a box in Section B, your replacement check can be direct-deposited into your bank account. Please see pages 3 and 4

for instructions. NOTE: Lost rollover checks CAN ONLY BE REPLACED BY A PAPER CHECK, not by direct deposit.

STATEMENT:

Although I have been informed by NYCERS that the type of check designated above in the amount of

[MM/DD/YYYY]

was issued to me and mailed to the following:

and dated

Address

Apt. Number

State

Zip Code

City

I hereby inform NYCERS that I have not received the above-mentioned check. I further state that I do not know where this check may

be at the present time, and that I am filing this form to have a replacement check issued to me in the same amount as the original check

issued by NYCERS. If other circumstances exist, please state briefly: (Example: Check was received but stolen or lost after receipt)

In the event that the original missing check comes into my possession at any time, I promise to return it immediately to NYCERS at the

above address. If at any time it is found that the original check has been cashed by me, I hereby authorize NYCERS to deduct the

amount of the check from any future payments.

Sign this form and have it notarized, Page 2

R11/17

Page 1 of 4

Form F399 - Affidavit Concerning Lost Check

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