Election Form for 25 Year Retirement Plan Section 89 RS 5475

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.