Form F234 - Agency'S Employee Status Change Notification
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1
2F234
NYCERS USE ONLY
*234*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Agency's Employee Status Change Notification
This form is to be completed by any agency to notify NYCERS of a status change for an employee who is ALREADY a NYCERS
member. Thank you for submitting this information; it will ensure that we update the member’s record and notify him/her of any
options.
THIS FORM MUST BE COMPLETED BY THE AGENCY ONLY
AND SIGNED BY THE AGENCY ON PAGE 2
EMPLOYEE INFORMATION
NYCERS Member Number
Last 4 Digits of SSN Title
Title Code
First Name
M.I.
Last Name
Address
Apt. Number
City
State
Zip Code
EMPLOYEE STATUS CHANGE
For the employee listed above, please complete the appropriate section:
[MM/DD/YYYY]
Resigned, terminated or was dismissed with an effective date of
/
/
.
Is on an approved leave for [check one]:
Medical
Child Care
Workers' Compensation
Union
Military Service
[MM/DD/YYYY]
[MM/DD/YYYY]
.
with an effective date from
/
/
to
/
/
Title change FROM:
Title Code
Title
TO:
Title Code
Title
[MM/DD/YYYY]
Reinstated and/or reassigned to previous status with an effective date of
/
/
.
Other [please specify]:
R02/17
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Parent category: Business