Form Rs 6410 - Application For 605a Accidental Disability Page 2

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16. DATES OF ACCIDENTS, WHERE THEY OCCURRED, AND WORKER’S COMPENSATION NUMBER(S) ASSIGNED**

17. DESCRIPTION OF THE ACCIDENT(S). ALSO DESCRIBE ANY OTHER OCCURRENCES THAT MAY BE RELATED TO YOUR CLAIMED

DISABILITY. (Use additional sheets if required)

18. THE FOLLOWING PERSON(S) WITNESSED THE ACCIDENT(S):

Witness Name

Date Witnessed

Witness Address

City, State and Zip Code

19. INFORMATION ABOUT YOUR INTENDED BENEFICIARY

Beneficiary

Relationship to you (if any)

Street

Date of Birth

City, State and Zip Code

Sex

I certify that the information contained on this form is true.

__________________________________________________________

_________________________________________________________

Applicant Name / Title (Please Print)

Applicant Signature (Sign Name in Full) / Date



RELATIONSHIP TO MEMBER:

Self

Employer

Other ___________________________________________________________

(If applicant is not the member or employer, you must submit original documentation that authorizes you to file)

* NOTE: In accordance with the Federal Privacy Act of 1974 you are hereby advised that disclosure of your Social Security account number is mandatory pursuant to Section

11, 34, 311 and 334 of the Retirement and Social Security Law. Your number will be used in identifying your retirement records and in the administration of the Retirement

System

** If Workers’ Compensation benefits are payable, member must apply for them. Accidental Disability Retirement Benefits are reduced by Workers’ Compensation

benefits.

PERSONAL PRIVACY PROTECTION LAW – The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide

information may interfere with timely payment of benefits. The System may be required to provide certain information to participating employers. The official responsible for record

maintenance is the Director of Member Services, NYS and Local Retirement Systems, Albany, NY 12244; 518-474-7736.

RS 6410 (Rev. 12/13)