Withdrawal Application Rs 5014

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Receipt Date
withdrawal Application
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
RS 5014
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
(Rev. 11/12)
This form is for terminating your membership in the New York State and Local Retirement Systems.
Please read the following:
You do not become eligible for return of your contributions (if any) until 15 days after separation from service.
If you have not made any contributions, there will be no payment due you. Membership may be terminated, but not before 30 days after separation from
service.
Any loan balance which exists at the time of termination will be deducted from your refund.
Tier 1, 2, 3 & 4 members with five years of credited service have vested rights. Tier 3 and 4 members with more than five but fewer than ten years of credited
service may terminate membership and forfeit their vested rights.
Tier 5 members do not have vested rights until they attain ten or more years of service.
Membership cannot be terminated if a member is vested with ten or more years of credited service.
If you have joined another retirement system operated by the State of New York or a political subdivision, you may be able to transfer your membership to
that system. To do so, do not complete this form but send for form RS 5223, Request to Transfer Membership. By transferring your entire membership to
another retirement system your contributions retain their tax-deferred status. If you do not transfer when the privilege is available, you may not be able
to get credit for this service at a later date.
this section to be completed by member
Instructions – Complete (print or type) items 1-9 below. You must sIgn the declaration, in ink. You must choose a payment option on the lower half of
this form. If any alterations are necessary, your corrections must be initiated.
to the comptroller of the state of new york:
I request that my membership in the retirement system be terminated and I apply for the return of contributions and interest credited on my account, if
any. In consideration of the termination of my membership I hereby waive for myself, my heirs and assigns all my right, title, and interest in the funds of
any and all benefits flowing from membership in the retirement system. I have terminated my employment and I am not now employed in any position in
government service in which membership in this retirement system is available.
I
am a Tier 1, 2, 3 or 4 member credited with at least five years of service and understand that I am eligible for a future benefit. As a vested
Tier 1, 2, 3 or 4 member, I could receive an estimate of my future benefits. By checking this box I am choosing to waive such estimate and that
my application be processed immediately.
1.
Full Name __________________________________________________
Please provide a telephone number where you can be reached
during the day. This will only be used if there are questions which
2.
Maiden Name (if applicable) ____________________________________
may delay the processing of your application.
(
)
3.
Social Security Number* ______________________________________
___________________________________
(Area Code) Telephone Number
4.
Last public employer __________________________________________
5.
Last day worked, if known _____________________________________
6.
Registration Number _________________________________________
7.
Date of Birth ________________________________________________
Month
Day
Year
8.
Your mailing address: ___________________________________________________________________________________________________
Street
City
State
Zip Code
9.
Payment Election
Please indicate your choice of only onE of the following payment options:
Issue payment without 30 day review and withhold 20 percent of the taxable portion: I have read the information regarding federal tax withholding
and rollovers of the distribution payable to me. I elect to receive the entire distribution rather than rolling over all or part of the taxable portion of such
distribution to a qualified plan or individual retirement account. I understand that Federal law requires that twenty percent of the taxable portion of
such distribution will be withheld for taxes pursuant to the Internal Revenue Code and applicable regulations. I further understand that under
applicable law and regulations, I have the right to review this notice for 30 days prior to making this election, and hereby waive such right.
Issue payment after 30 day review and withhold 20 percent of the taxable portion: I have read the information regarding federal tax withholding
and rollovers of the distribution payable to me. I elect to receive the entire distribution rather than rolling over all or part of the taxable portion of such
distribution to a qualified plan or individual retirement account. I understand that Federal law requires that twenty percent of the taxable portion of
such distribution will be withheld from the payment, pursuant to the Internal Revenue Code and applicable regulations. I further understand that I
have the right to review this notice for 30 days prior to the processing of my refund and that during that period no payment will be made.
Rollover taxable portion to qualified plan or IRA and avoid 20 percent withholding: I have read the information regarding federal tax withholding
and rollovers of the distribution payable to me. I elect to rollover the taxable portion of such distribution to a qualified plan or individual retirement
account as indicated on the Trustee-to-Trustee section of this application.
______________________________________________
______________________________________
Signature
Date
PlEAsE go to bAck of thIs foRm foR moRE InfoRmAtIon.
coPIEs oR fAcsImIlEs whIch do not contAIn oRIgInAl sIgnAtuREs ARE not AccEPtAblE.

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