Survivor'S Benefit Program Eligibility Of Retired Employee For Survivor'S Benefit

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SURVIVOR’S BENEFIT PROGRAM
Eligibility of Retired Employee
for Survivor’s Benefit
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
RS 6355
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
(Rev. 3/14)
PART A - TO BE COMPLETED BY DEPARTMENT OR AGENCY (See instructions on reverse)
1. Name (Last) _________________________________________ (First) ___________________________ (MI) ________ 2. Social Security Number _______________________
3. Date of Birth ____________________ 4. Date of Appt. _____________________ 5. Agency Code ____________________ 6. Payroll Item No. _________________________
7. Name(s) of Retirement System(s) ______________________________________ 8. Ret. Reg. No. ____________________ 9. Title __________________________________
10. Eligibility - Check box “a” and other applicable boxes (if box ‘a’ does not apply, see detailed instructions on reverse).
a.
Employee had ten years of full-time State service within the last 15 years. (Annual salary of at least 1,000 hours times the state minimum wage during such period or
regularly scheduled work week of 20 hours or more).
b.
Employee retired from the system named in number 7 effective. ___________________________
(Date)
c.
Employee retired from the State University or Department of Education optional retirement program after attaining age 55 and began receiving retirement allowance
within 90 days of last day on the payroll.
d.
Employee terminated state service effective ___________________________
after attaining age 62.
(Date)
e.
Employee laid off effective ___________________________
and retired within one year of layoff date.
(Date)
11. I certify that the information above is as shown in the records at this agency and I believe the same are true and correct. This employee has received Form VO 1860.
Signature _________________________________________________ Title _________________________________________________ Phone No. ______________________
Agency ___________________________________________________ Address ______________________________________________ Date __________________________
PART B - TO BE COMPLETED BY SURVIVOR’S BENEFIT PROGRAM
ELIGIBLE
INELIGIBLE
REASON:
Signature _________________________________________________ Date ________________________
PART C - TO BE COMPLETED BY EMPLOYEE AT TIME OF INITIAL RETIREMENT (DO NOT USE AS A CHANGE OF BENEFICIARY IF PREVIOUSLY RETIRED.)
DESIGNATION OF BENEFICIARY — If you are not a member of a retirement system or pension plan supported by State funds or if you are a member but have not designated
a beneficiary to such system to receive retirement benefits (because you have chosen Option 0), you should check box A, and designate a beneficiary below for the Survivor’s
Benefit Program. If you are a member of a retirement system and have selected an option under which you have designated a beneficiary (any option other than 0), the survivor’s
benefit must be paid to the same beneficiary designated to the retirement system. Therefore, box B should be checked.
A.
I have selected Option 0 and have, therefore, not designated a beneficiary to a retirement system supported by State funds to receive retirement benefits. I authorize
the Comptroller to pay to the beneficiary named below any survivor’s benefit due on my behalf. I understand that I can change this designation at any time.
(Note: Also check A. if not a member of any retirement system.)
(COMPLETE DESIGNATION OF BENEFICIARY(IES) ONLY IF YOU HAVE SELECTED OPTION 0 OR IF YOU DO NOT BELONG TO ANY RETIREMENT SYSTEM)
DESIGNATION OF PRIMARY BENEFICIARY(IES)
USE YOUR BENEFICIARY’S GIVEN (FIRST) NAME, (MARY SMITH, NOT MRS. JOHN SMITH) PLEASE PRINT PLAINLY OR TYPE.
Name __________________________________________________________________________
Name __________________________________________________________________________
Relationship ______________________________________________ Birth Date ______________
Relationship ______________________________________________ Birth Date ______________
Soc. Sec. No.* ____________________________________________ Sex ___________________
Soc. Sec. No.* ____________________________________________ Sex ___________________
Address (Street, City, State, Zip) _____________________________________________________
Address (Street, City, State, Zip) _____________________________________________________
DESIGNATION OF CONTINGENT BENEFICIARY(IES)
If all the above named beneficiaries die before I do, any amount payable on my behalf should be paid to the following. If I have named more than one beneficiary, it is my intention
that those living at the time of my death should share any benefit equally. This designation revokes all previous designations I have made.
Name __________________________________________________________________________
Name __________________________________________________________________________
Relationship ______________________________________________ Birth Date ______________
Relationship ______________________________________________ Birth Date ______________
Soc. Sec. No.* ____________________________________________ Sex ___________________
Soc. Sec. No.* ____________________________________________ Sex ___________________
Address (Street, City, State, Zip) _____________________________________________________
Address (Street, City, State, Zip) _____________________________________________________
to share and share alike unless otherwise specified of those surviving the death benefit payable under the Survivor’s Benefit Program as the result of my death after retirement.
I reserve the right to change the above beneficiaries at any time without their consent. I hereby direct that, should I survive the before mentioned beneficiaries, the amount which
otherwise would have been payable to them as hereinabove set forth, shall be paid to my Estate or to such other beneficiary as I shall hereafter designate, by written designation
filed with the Comptroller in accordance with the rules and regulations prescribed. I understand that the above designation of beneficiary(ies) is for my death benefit under the
Survivor’s Benefit Program only, and does not affect any designation of beneficary(ies) made in conjunction with my retirement benefits.
B.
I have selected an option other than 0 and understand that the survivor’s benefit must be paid to the same beneficiary(ies) designated to the retirement system.
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.
Employee’s Signature ____________________________________________________________________________________________________________________________
Street Address ____________________________________________________________________ City __________________________ State ______ Zip Code ____________
ACkNOwLEDGEMENT
To be Completed by a Notary Public
State of _______________________________________________________________ County of __________________________________________________________ ss:
On this ____________ day of ______________________, _______, before me personally appeared _____________________________________ to me known and known to me
to be the same person described in and who executed the foregoing instrument, and __he duly acknowledged to me that __he executed the same.
(Signature of Officer) _____________________________________________________
Notary Stamp Must Be Affixed
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 and Employer Services, New York State and
Local Retirement System, 110 State Street, Albany, NY 12244; Telephone Number 1-866-805-0990 or 518-474-7736.
*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.

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