Fillable Withdrawal Application Rs 5014 (Page 4 of 4) in pdf

RS 5014 (Rev. 11/12) Page 4

to bE comPlEtEd by EmPloyER

this section must be completed if you were employed by other than a state agency, and have terminated your last public employment within

the last twelve months.

I certify that the member was separated from employment on

___________________________________

and is not on any authorized leave of absence.

The member’s name last appeared, or will appear on the payroll report for the month of

__________________________.

This report was, or will be, sent to the Retirement System on or about

________________________________________.

Gross earnings for the final month were

$_______________________,

and the retirement contributions, if any, were as follows:

Normal (or COESC)

$________________

Arrears

$______________________

Loan

$_______________________

(

)

______________________________________

__________________________

___________________________

Printed Name

Authorized Signature

Title

Telephone Number

the next section must be completed if you want the Retirement system to transfer your tax-deferred funds.

dIREct tRustEE-to-tRustEE tRAnsfER

mEmbER IdEntIfIcAtIon

I, ___________________________________________________________________

hereby request that the Comptroller of the State of New York as

trustee of the New York State and Local Retirement Systems transfer the taxable portion of the non-periodic distribution I have applied for to my account

with ________________________________________________________, the trustee for my IRA or other qualified retirement plan.

____________________________________________

_____________________

Social Security Number*

___________________________

Signature

Date

tRustEE InfoRmAtIon (To be completed by a representative of your financial institution.)

Some financial institutions require Letters of Acceptance in order for this transfer to take place. If any documentation is necessary to complete your transfer

of funds, it must accompany this application.

____________________________________ has established an account with us and we request the transfer proceeds as noted above to be sent to us.

The account number for this individual is _________________________________________.

Please make the check payable to:

_____________________________________________ as ______ Trustee for the ______ IRA

Custodian

Qualified Plan

_______

of ____________________________________________________.

______________________________________________________

__________________

Trustee/Custodian Signature

Date

(

)

Trustee/Custodian Address: ________________________________________________

Telephone Number ___

_____________________________

________________________________________________

Return this entire document to:

new york state and local Retirement system

withdrawals unit – mail drop 5-8

110 state street

Albany, new york 12244

only thE oRIgInAl of thIs foRm wIll bE PRocEssEd.

coPIEs oR fAcsImIlEs whIch do not contAIn oRIgInAl sIgnAtuREs ARE not AccEPtAblE.

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 Services, New York State and Local

Retirement System, Albany, NY 12244; Telephone Number (866) 805-0990 or (518) 474-7736 in the Albany, New York area.

*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, 34, 311

and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of the Retirement System.

Withdrawal Application Rs 5014 Page 4

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