Form F355 - Payroll Verification Affidavit
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1F355
NYCERS USE ONLY
*355*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Payroll Verification Affidavit
To help prevent fraud and ensure your identity is secured, we ask that you complete and return this form to the mailing address below
for periodic pension verification purposes. Your response is mandatory. If you have any questions regarding this form, please
contact our Call Center at (347) 643-3000 or visit our Customer Service Center at 340 Jay Street, Brooklyn, NY 11201.
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.
Phone Number
Pension Number
Last 4 Digits of SSN
(
)
First Name
M.I.
Last Name
Address
Apt. Number
City
State
Zip Code
I, _________________________________, being duly sworn depose and claim the following:
I reside at the above address, and I am eligible to continue receiving monthly payments from the New York City Employees’
Retirement System.
Signature of Pensioner
Date
Pursuant to the Penal Code of the State of New York, offering a document containing false statements or false information
constitutes a felony punishable by a maximum of 4 years imprisonment. All documents suspected of containing false statements
will be referred to the New York City Department of Investigation for investigation.
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
R12/16
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