Form F544 - Revision Form

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F544
NYCERS USE ONLY
*544*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Revision Form
No advance (partial) pension payment will be sent to you until NYCERS has a copy of your birth certificate on file.
Pension Number
Last 4 Digits of SSN
Member Number
First Name
M.I.
Last Name
[MM/DD/YYYY]
Date of Checks
1.
/
/
Gross amount of Check(s)
/
/
2.
Gross amount of Check(s)
3.
/
/
Gross amount of Check(s)
/
/
4.
Gross amount of Check(s)
5.
Gross amount of Check(s)
/
/
Signature of Member
Date
R12/16
Page 1 of 1

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