Request For Previous Service Rs 5042
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1Request for Previous Service
Office of the New York State Comptroller
New York State and Local Retirement System
RS 5042
Employees’ Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
(Rev. 6/11)
Previous Name
Name _____________________________________
D.O.B. _________________
Registration Number ______________________ S.S. Number ________________________
You May Have Been Using
______________________
(Print or Type)
By Whom Currently Employed
____________________________________________________________________________________
Department Where Now Employed ____________________________________________________
(Indicate whether State, County, City, Town, Village, Special District, etc.)
RECORD OF ADDITIONAL SERVICE NOT INCLUDED IN FORMER STATEMENT OF SERVICES INCLUDING MILITARY SERVICE
Public employer you
FROM
TO
LENGTH OF SERVICE
Name of Department
Registration Number
worked for during previous
Name of Retirement System
or Agency for
(During previous
Title of Position(s)
services claimed (i.e-State,
(If you were a member)
that employer
membership-if known)
Mo.
Day
Year
Mo.
Day
Year
Mo.
Day
Year
County, Town, etc.)
This form is to request additional retirement service credit
ADDITIONAL TOTAL SERVICE CLAIMED
Current Home Address ___________________________________________________________________________
Telephone Number
_______________________________________________________
No.
Street
_______________________________________________________ _
_________ ___________
__________________
Signed ________________________________________________________________
City
State
Zip Code
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