Form Rs 6410 - Application For 605a Accidental Disability
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1
2
3Please return this application to the Retirement System in an envelope marked “Personal and Confidential, Mail Drop 7-1”
RECEIVED
Application for 605A
Accidental Disability
(Available for Uniformed Court Officers)
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
RS 6410
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
(Rev. 12/13)
INSTRUCTIONS: Please print plainly or type. The application must be signed on reverse side.
Please call our Call Center at 1-866-805-0990 if you need help completing this application.
INFORMATION ABOUT YOU
1. NAME
2. SEX:
3. SOCIAL SECURITY NUMBER*
XXX-XX-
M
F
4. ADDRESS
5. REGISTRATION NUMBER
6. DATE OF BIRTH
/
/
7. TELEPHONE NUMBERS:
HOME (
)
8. EMPLOYER
WORK (
)
CELL (
)
9. PAYROLL TITLE
10. LENGTH OF SERVICE
_________ Years _________Months
11. PAYROLL STATUS: On Payroll & Receiving Salary?
Yes
No If No, Explain.
12. FOR UNITED STATES TAX WITHHOLDING AND REPORTING PURPOSES (PLEASE CHECK ONE),
I AM A:
U.S. CITIZEN
RESIDENT ALIEN
NONRESIDENT ALIEN
13. I AM PERMANENTLY DISABLED BECAUSE OF THE FOLLOWING MEDICAL CONDITION(S): (Use additional sheets if required)
14. I HAVE BEEN TREATED BY THE FOLLOWING DOCTORS: (Use additional sheets if required)
Primary Care Physician
Doctor
Doctor
Internal Med/Family Practitioner
Medical Speciality
Medical Speciality
Street
Street
Street
City, State and Zip Code
City, State and Zip Code
City, State and Zip Code
Doctor
Doctor
Doctor
Medical Speciality
Medical Speciality
Medical Speciality
Street
Street
Street
City, State and Zip Code
City, State and Zip Code
City, State and Zip Code
15. LIST HOSPITALIZATIONS, IF ANY. (Use additional sheets if required)
Hospital
Dates of Admission
Hospital
Dates of Admission
Street
Street
City, State and Zip Code
City, State and Zip Code
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