Survivor'S Benefit Program Eligibility Of Retired Employee For Survivor'S Benefit Page 2

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INSTRUCTIONS FOR COMPLETION OF FORM RS 6355

PURPOSE

This form is to be used by a State department or agency to report the separation of an employee who meets the eligibility requirements of the Survivor’s Benefit

Program for retired employees. The form is also to be used for designation of a beneficiary by the separating employee at the time of separation, when re-

quired.

PREPARATION

Type an original and one copy. Complete items in Part A and have employee complete Part C. All items must be completed; indicate “none” or “unknown” if

necessary, and check appropriate boxes. Forward original to Survivor’s Benefit Program and give copy to employee.

PART A

ITEM NO. 3

If employee does not retire from a public pension plan, a copy of a certificate of birth or other proof of his/her age must be attached to this form.

ITEM NO. 4

Enter the original date of appointment to the first State position held by the employee.

ITEM NO. 7

Enter the name or names of any retirement systems or pension plans supported by State funds of which the employee was an ACTIVE, vested, or discontinued

member at time of separation. If employee’s status was other than ACTIVE, so indicate, e.g., Employees’ Retirement System (discontinued). If employee was

not a member of either the NYS Employees’ Retirement System or Police and Fire Retirement System, include a detailed statement of employment history. If

employee was a member or prior member of more than one retirement system, list all retirement systems.

ITEM NO. 8

Enter a registration number for each pension plan entered in Item No. 7. If a member of more than one system, list all registration numbers.

ITEM NO. 10

Periods during which an employee was off the payroll on authorized leave of absence shall be counted as State Service, not exceeding a total of three months

in any one calendar year and not exceeding three months in any one continuous period of such absence.

A legislative or seasonal employee who served in a position wherein the nature of service is not continuous throughout the year but recurs or is expected to recur

in each successive year in essentially the same form shall be deemed to have been on authorized leave of absence during the period between successive annual

periods of service.

If the employee was compensated on an annual salary basis but was paid over a period of less than 12 months, he/she is deemed to have been actively on the

payroll during the entire period covered by the payment of that annual salary.

An employee who retired from State service while off the payroll on authorized leave of absence is deemed to have been in State service upon such retirement.

An employee who resigns or otherwise terminates State service while off the payroll on authorized leave of absence is deemed to have terminated State service

upon the actual effective date of such termination and is deemed to have been in State service on such actual date of termination. An employee who is laid

off from his or her position because of the curtailment of the State services, is considered to be on an authorized leave without pay for one year following the

layoff.

Item No. 10 should be checked and completed as follows:

1. Box a. should be checked in every case to confirm eligibility. If Box a. does not apply, forms should not be submitted except upon specific request of the

Survivor’s Benefit Program. If it is not certain whether Box a. applies, forms should be submitted.

2. Box b. should be checked and completed if employee is retiring from a public pension plan.

3. Box c. should be checked in addition to a. and b. if employee is retiring from State University or Department of Education optional retirement program.

4. Box d. should be checked and completed if employee is not retiring from a public pension plan but is leaving State service after attaining age 62 and proof

of age must be attached to this form.

5. Box e. should be checked and completed if employee’s separation from service was due to a layoff (rather than a resignation or termination). Retirement

date shown in Box b. must be within one year from date of layoff.

A detailed statement of employment history must be attached to Form RS 6355 to substantiate the requirement of ten years of full time service for employees

in the following categories or agencies:

1. Teachers’ Retirement System Member

2. TIAA-CREF Member

3. Non-retirement System Member

4. Unclassified Service

5. Legislative Branch

6. Judicial Branch

7. Cornell University and Alfred University

8. Forest Fire Observers (Conservation)

9. Palisades Interstate Park Commission

PART C

This employment history should show all appointments, status changes, leaves, separations, and their effective dates. If a complete employment record is main-

tained by the agency, a photocopy will be sufficient. If not, the agency should reconstruct the employee’s work history from available records. If service for any

period was other than full time (regular work schedule of at least 20 hours per week or annual salary at least $2,000) please so indicate on the statement.

This part must be completed by the eligible employee in every case. If the employee is not a member of a pension plan supported by State funds or if he/she

is a member but has not designated a beneficiary to receive his/her retirement benefits, he/she should check Box a., designate a beneficiary as indicated, sign

his/her name, and enter date and address.

The employee must enter the full name (abbreviations not acceptable), complete date of birth (list approximate age if exact date unknown) and Social Security

number (if known) of his/her beneficiary. If the beneficiary is a married female, her given name must be entered on the form (Mrs. John Smith is not accept-

able). Be sure beneficiary’s address is complete - number, street address, city, state and zip code.

NOTE: The employee may designate more than one beneficiary. If he/she wishes to do this he/she should merely list the names and addresses of such persons.

Benefits will be divided equally among them unless otherwise specified. Attachments to your beneficiary form are not acceptable. If needed you may double up

on lines; including names, birthdates, addresses and relationships.

The employee may designate contingent beneficiaries. He/she may not place any restrictions upon his/her designation such as “in trust for” or “upon reaching

age 21”. If the employee has designated a beneficiary to a pension plan supported by State funds to receive his/her retirement benefits upon his/her death, he/

she should check Box b., sign his/her name and enter the date and his/her address. He/she should not enter the name of beneficiary on the Form RS 6355.

If an eligible employee fails to designate a beneficiary to receive his/her retirement benefits, or on Form RS 6355 as described above, the survivor’s benefit will be

paid to his/her estate. In some cases, the payment may not be made in accordance with the employee’s wish. For this reason, it is imperative that all employees

designate a beneficiary as required and that such designation be complete, accurate, and legible.

RS 6355 (Rev. 3/07)

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