Election Form for 25 Year Retirement Plan Section 89 RS 5475 Office of the New York State Comptroller New York State and Local Retirement System Employees’ Retirement System Police and Fire Retirement System 110 State Street, Albany, New York 12244-0001 (10/89) Tier 3 and Tier 4 Members Only IMPORTANT: This Election and the waiver of Article 15 rights are IRREVOCABLE TO THE COMPTROLLER OF THE STATE OF NEW YORK: I hereby elect to contribute under the provisions of Section 89 of the Retirement and Social Security Law as provided by Chapter 578 of the Laws of 1989 which provides for a retirement allowance of one-half final average salary upon the completion of 25 years of creditable service. I understand that by filing this election waive all rights, benefits, and privileges earned or available to an Article 15 member. I also understand that if I do not complete 25 years of creditable service, any allowance I receive will be reduced at age 62 by an offset for Social Security. Payroll Title______________________________________ Member’s Mailing Address (Please Print) Signature________________________________________ Name___________________________________________ Registration Number_______________________________ Address_________________________________________ Social Security Number*____________________________ _______________________________________________ ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC This election form is to be completed only by a qualified security hospital treatment assistant, security hospital senior treatment assistant, security hospital supervising treatment assistant or security hospital treatment chief. It must be filed with the Comptroller on or before December 31, 1989 or within one year after such person becomes employed in an eligible title, whichever date is later. A member who elects Section 89 may not withdraw this election at any time. State of_________________________________________ County of _______________________________________ On the_____day of________ in the year_____ before me, the undersigned, personally appeared ____________________, _______________________________________________ City State Zip Code personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. NOTARY PUBLIC (Please sign and affix stamp) *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. This form is invalid unless applicant is currently a Tier 3 or Tier 4 member of the New York State and Local Retirement System.
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