Retirement Option Election Form For Tier 1 Members RS 6268-A

New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
Retirement Option Election Form
For Tier 1 Members
For Designating Multiple Beneficiaries
RS 6268-A
(Rev. 12/04)
MAKE NO ALTERATIONS TO THIS FORM. Please review carefully the options available and the instructions provided. You must 1) elect an option by checking the
appropriate box, 2) sign the completed form, 3) have it notarized, and 4) return it promptly.
IMPORTANT: You must file your Option Election form before your pension becomes payable, which is the first day of the month following your retirement. You
have up to 30 days after your pension benefit becomes payable to change your option selection. If your election is not timely, by law, we must process your
retirement as if you had selected the Cash Refund-Contributions (Option 1/2) with your estate named as beneficiary.
INFORMATION ABOUT YOU
1. Name (First, Middle Initial, Last)
3. Social Security Number*
2. Address
4. Registration Number
___________________________________________________________
___________________________________________________________
5. Date of Birth
Month
Day
Year
___________________________________________________________
*Social Security Number required. (See statement on reverse side.)
To The Comptroller of The State of New York:
Cash Refund - Contributions
(Option 1/2)
†
I elect to receive a reduced lifetime retirement allowance. I understand that all payments shall
stop at my death, except for the remaining balance of my total member contributions, if any.
Pay any such balance to my beneficiary(ies). If my beneficiary(ies) predeceases me, pay my
Estate or another beneficiary I may name.
†
I elect to receive a reduced lifetime retirement allowance. If I die before I receive total
retirement allowance payments equal to the Initial Value, pay any remainder to my
beneficiary(ies). If my beneficiary(ies) predeceases me, pay my Estate or another beneficiary
I may name.
†
I elect to receive a reduced lifetime retirement allowance. If I die within five years after my
retirement date, continue paying my retirement allowance for the remainder of the five years to
my beneficiary(ies). If my beneficiary(ies) predeceases me, but I also die within five years
following my retirement, continue payments for the rest of the five year period to another
beneficiary I may name. If there is no surviving beneficiary, make a lump sum payment to my
Estate. If I die more than five years after my retirement date, stop all payments at my death.
†
I elect to receive a reduced lifetime retirement allowance. If I die within ten years after my
retirement date, continue paying my retirement allowance for the remainder of the ten years to
my beneficiary(ies). If my beneficiary(ies) predeceases me, but I also die within ten years
following my retirement, continue payments for the rest of the ten year period to another
beneficiary I may name. If there is no surviving beneficiary, make a lump sum payment to my
Estate. If I die more than ten years after my retirement date, stop all payments at my death.
005
Cash Refund - Initial Value
(Option 1)
001
Five Year Certain
006
Ten Year Certain
007
Electing an Option
The option you elect is important to both you and your beneficiary. Be sure you understand the nature of each option, and elect the one that best fulfills
your needs. Also, be sure that you have checked the proper box for the option that you wish to elect. On this form, you are selecting a method of
payment. When you have completed this form and have had it notarized, the original should be returned to: New York State and Local Retirement
System, 110 State Street, Albany, New York 12244. We will acknowledge receipt of the option selection by sending you a letter.
Designating a Beneficiary
If you elect a Cash Refund Option or one of the Years Certain Options, you may designate more than one beneficiary.You may designate your Estate as
beneficiary. Under these options, you may change your beneficiary at any time. For each change of beneficiary(ies), you must submit a form which can be
obtained from the Retirement System. If you wish to elect one of the Joint Allowance or Pop-Up options on which you may name only one beneficiary, you
should request the proper option form immediately.
If you wish to elect the Single Life Allowance, which requires no beneficiary, you should request the proper form immediately.
Information Services
Information Representatives are available at 16 consultation sites throughout New York State. To find the one nearest you, visit our website at
www.osc.state.ny.us/retire. You can also contact our Call Center toll-free at (866) 805-0990, or (518) 474-7736 in the Albany area.
DESIGNATION OF PRIMARY BENEFICIARY(IES)
Use the beneficiary’s given name: Mary Smith NOT Mrs. John Smith. Please print plainly or type.
I hereby name the following beneficiary(ies) to receive any benefit payable on my behalf. If I have named more than one beneficiary, it is my
intention that those living at the time of my death should share equally any benefit payable.
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)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
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)
Use the beneficiary’s given name: Mary Smith NOT Mrs. John Smith. Please print plainly or type.
If all the above named beneficiary(ies) die before I do, any benefits payable on my behalf should be paid to the following. If I have
named more than one beneficiary, those living at the time of my death should share any benefit equally.
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)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
*Social Security Number required. (See statement below.)
Retiree’s Signature (sign name in full)
Acknowledgement To Be Completed by a Notary Public
State of____________________________________________________ County of _____________________________________________________
On the _______________ day of ______________________ in the year _____________________________, before me, the undersigned, personally
appeared___________________________________________________________ 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 your 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.
Personal Privacy Protection Law
The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide information may interfere with the
timely payment of benefits. The System may be required to provide certain information to participating employers. The official responsible for record maintenance is the
Director of Member and Employer Services, NYS and Local Retirement System, Albany, NY 12244; call toll-free at 1-866-805-0990 or 518-474-7736 in the Albany area.
RS 6268-A (Rev. 12/04)