Form Rs 5223 - Application For Transfer Of Membership

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RECEIVED

Application for

Transfer of Membership

Office of the New York State Comptroller

RS 5223

New York State and Local Retirement System

Employees’ Retirement System

Police and Fire Retirement System

(Rev. 8/09)

110 State Street, Albany, New York 12244-0001

THIS FORM IS TO BE USED ONLY TO TRANSFER FROM THE NEW YORK STATE & LOCAL RETIREMENT SYSTEM TO ANOTHER PUBLIC

RETIREMENT SYSTEM IN NEW YORK STATE.

This transfer application is irrevocable. Once this transfer application is filed or received by the Retirement System your transfer is effective.

Under certain circumstances it may not be beneficial to transfer your membership. If you have any questions concerning your transfer or if you are

covered by a special plan, you should contact Benefit Information Services at 1-866-805-0990 before completing this application.

INSTRUCTIONS

Please print all requested information in ink.

Forms completed in pencil will be rejected. Sign the completed form and have it notarized. Return the

completed form to the NYSLRS at the address shown above (not your employer). Your transfer will be effective on the date we receive the completed

application assuming you meet all legal requirements, although the administrative processing will take several months to complete.

*Social Security No: _

__________________________________________

Registration No. (if known Name) _______________________________

Name

___

___________________________________________________

Date of Birth________________________________________________

(

) _______________________________________

Address

___

_________________________________________________

Home Phone ________

( _______

)

City _

______________________________

State

____

Zip

_________

Work Phone

_ _

_______________________________________

Former Employer _

____________________________________________

Date Terminated/Leave of Absence ______________________________

Current Employer

____________________________________________

Date Appointed______________________________________________

TO THE COMPTROLLER OF THE STATE OF NEW YORK:

I request that my membership, reserves, and accumulated contributions, if any, standing to my credit in the New York State & Local Retirement System be

transferred to the

_________________________________________________________

Retirement System where I am currently registered as a member.

I understand that this application to transfer is irrevocable.

Signed

_____________________________________________

Date

________________________

ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC

State of

________________________________________

County of

__________________________________

On the

____

day of

_______

in the year

______

before me, the undersigned, personally appeared

_____________________________________________,

personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within

instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument,

the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

___

______________________________________________

NOTARY PUBLIC (Please sign and affix stamp)

DO NOT WRITE BELOW THIS LINE

CERTIFICATION

(To be completed by the system to which transfer is being made)

I certify that the above named individual has been registered to membership in the ___________________________________________ Retirement

System on __________________ (date of membership) under membership number _______________________________. I further certify that the

requested membership is currently active and the requested transfer can be processed.

The date last reported to our system was _______________________

Signature__________________________________________

Date____________________

Title______________________________________________

PERSONAL PRIVACY PROTECTION LAW

In accordance with the Personal Privacy Law, you are hereby advised that pursuant to the Retirement and Social Security Law, the Retirement System is required to maintain records. The records are necessary to

determine eligibility for and to calculate benefits. Failure to provide information may result in the failure to pay benefits. The System may provide certain information to participating employers. The official responsible for

maintaining these records is the Director of Member & Employer Services, New York State and Local Retirement System, 110 State Street, Albany, NY 12244-0001; Telephone Number (518) 474-2602.

SOCIAL SECURITY DISCLOSURE REQUIREMENT

In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the Social Security Account Number is mandatory pursuant to Sections 11 and 34 of the Retirement and Social Security Law.

The number will be used in identifying retirement records and in the administration of the Retirement System.