Form F234 - Agency'S Employee Status Change Notification Page 2
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2F234
NYCERS USE ONLY
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Member Number
Last 4 Digits of SSN
To report a NYCERS member who has transferred IN to your agency, please use Form #233.
AGENCY INFORMATION
Agency Name
Agency Bank Number
Personnel/Benefits Representative
Phone Number
E-mail Address
(
)
Signature of Personnel/Benefits Representative
Date
R02/17
Page 2 of 2
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Parent category: Business