All forms and brochures are available in PDF format; Adobe Reader is required. Please hand-deliver all forms that are time-sensitive to our Customer Service Center. Considerable risk of undocumented or lost applications is taken when mailing such documents. We have also listed some forms that can be mailed to you. Please contact our Call Center at 347-643-3000 to request these forms.

If you submit an original vital record or legal document to NYCERS and would like it to be returned to you, please attach a note to the item requesting that it be returned, and include the return mailing address with the note.

  1. FORMS AND AFFIDAVITS
  1. BROCHURES
  1. FACT SHEETS

Membership
Birth Evidence Affidavit

Special Plan Election
Beneficiaries
Special Plan Opt Out
Transferring
Buy-Back
Military Buy-Back
Loan
Refund
Vesting
Power of Attorney
Service Retirement
Retirement Options
Disability
Pensioner Specific
Request Information
Lost Check
Address Change
Name change

Membership
Special Plans
Buy-Back
Military Buy-Back
Loan
Refund
Vesting
Leaving City Service
Service Retirement
Retirement Options
Disability
Calculating Final Average Salary
Calculating Retirement Benefit
Pensioner Specific

Birth Evidence Alternatives (see also
Birth Evidence Affidavit
)

Guide to Your Pension Check
Loan Default Fact Sheet
Loan Reduction Factors
Loan Taxability Fact Sheet
Pension Payment Schedule
Physically Taxing Titles
Processing Death Benefits
Proof of Identity
The Road to Your NYCERS Retirement
Tier 6 22-Year Plan Fact Sheet
Tier 6 Basic Plan Fact Sheet
Tier 6 Special Plans Fact Sheet
WTC Disability Law Fact Sheet

# Tier(s) Form/Brochure Name PDF Download
MEMBERSHIP FORMS
101 1,2 Application for Membership for Tier 1 and Tier 2 Members Download Now
103 3,4,6 Application for Membership for NYCERS-Eligible Employees Download Now
181 ALL Membership / Tier Reinstatement Download Now
212 1,2 Increased-Take-Home-Pay (ITHP) Waiver/Cancellation Download Now
311 1,2 Application to Cancel Rate of Deduction Download Now

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MEMBERSHIP BROCHURES
968 ALL NYCERS Membership at a Glance Download Now
967 ALL PIN Brochure Download Now
905 ALL Membership Reinstatement Download Now

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PHYSICALLY TAXING TITLES Fact Sheet
712 4 Physically Taxing Titles Download Now

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SPECIAL PLAN FORMS
 
161 3 Election of 20-Year Retirement Program – Tier 3 NYC Correction Members of the Rank of Captain or Above Download Now
162 1,2 Election of Career Pension Plan or ISF - Tier 1 and Tier 2 Members Download Now
165 2,3 Election of 20-Year Retirement Program -Tier 2 and Tier 3 NYC Correction Members Below the Rank of Captain Download Now
166 2,3 Election of 20-Year Retirement Program – Tier 2 or Tier 3 NYC Correction Members of the Rank of Captain or Above Download Now
169 1,2,4 Election of Optional Dispatcher 25-Year Retirement Program Download Now
170 1,2,4 Election of Optional EMT 25-Year Retirement program Download Now
175 2,4 Election of 20-year Sanitation Retirement Program Download Now
183 2,4 25-Year/Age 50 Plan Election Form - Automotive Service Titles - Tiers 2 and 4 Download Now
184 2, 4 25-Year Plan Election Form - Deputy Sheriffs - Tiers 2 and 4 Download Now
185 1,2,4 25-Year Plan Election Form - Special Officer Titles - Tiers 1, 2 and 4 Download Now
189 2,4 25 Year Plan Election Form - (911) Police Communications Titles Download Now
192 2 Election of the Optional 20-Year Retirement Program For Tier 2 Investigator Members Download Now
193 2 Election of the Optional 25-Year Retirement Program For Tier 2 Investigator Members Download Now
219 1,2 Election of Coverage Under the Transit Non-Contributory 20-Year Retirement Plan Download Now

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SPECIAL PLAN BROCHURES
910 4 Transit 25-55 Tier 4 Download Now
914 2 The Automotive Service Worker 25-Year and Age 50 Retirement Program (50/25) - For Tier 2 Members Download Now
916 2 Special Officer 25-Year Retirement Program - For Tier 2 Members Download Now
917 3 Correction Force 20-Year Retirement Plan Download Now
918 3 Correction Officer 20-Year Retirement Plan Download Now
920 3 Correction Officer 25-Year Retirement Plan Download Now
932 4 The Automotive Service Worker 25-Year and Age 50 Retirement Program (50/25) - For Tier 4 Members Download Now
933 4 Deputy Sheriff 25-Year Retirement Program - For Tier 4 Members Download Now
934 4 Special Officer 25-Year Retirement Program - For Tier 4 Members Download Now
935 4 Sanitation 20-Year Retirement Program Download Now
936 4 EMT 25-Year Retirement Plan - Tier 4 Download Now
937 4 Dispatcher 25-Year Plan For Tier 4 Members Download Now
938 4 MTA Bridges and Tunnels 20-Year, Age 50 Plan For Tier 4 Members Download Now
940 2 911 COMMUNICATIONS OPERATORS/25 YEAR PLAN For Tier 2 Members Download Now
941 4 911 COMMUNICATIONS OPERATORS/25 YEAR PLAN For Tier 4 Members Download Now
942 2 D.A. INVESTIGATORS/20 YEAR PLAN For Tier 2 Members Download Now
943 2 D.A. INVESTIGATORS/25 YEAR PLAN For Tier 2 Members Download Now
944 4 55/25 Retirement Plan For Tier 4 Members Download Now
945 4 57/5 Retirement Plan For Tier 4 Members Download Now
946 4 62/5 Retirement Plan for Tier 4 Members Download Now
985 6 Triborough Bridge and Tunnel Authority 20-Year/Age 50 Retirement Plan for Tier 6 Members Download Now
986 6 Transit Operating Force 25-Year/Age 55 Retirement Plan for Tier 6 Members Download Now
987 6 Emergency Medical Technician 25-Year Retirement Plan for Tier 6 Members Download Now
988 6 Dispatcher 25-Year Retirement Plan for Tier 6 Members Download Now
989 6

Deputy Sheriff 25-Year Retirement Plan for Tier 6 Members

Download Now
990 6 Special Peace Officer 25-Year Retirement Plan for Tier 6 Members Download Now
991 6

Automotive Member 25-Year/Age 50 Retirement Plan for Tier 6 Members

Download Now
992 6

Police Communications Technician 25-Year Retirement Plan for Tier 6 Members

Download Now
993 6 63/10 Retirement Plan for Tier 6 Members (Tier 6 Basic Plan) Download Now
994 6

Uniformed Correction Force 22-Year Plan for Tier 6 Members

Download Now
995 6 Uniformed Sanitation Force 22-Year Plan for Tier 6 Members Download Now
996 6

DA Investigators 22-Year Plan for Tier 6 Members

Download Now

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BENEFICIARIES FORMS
131 1,2 Designation of Beneficiaries for Tier 1 and Tier 2 Members Download Now
133 3,4,6 Designation of Beneficiary for Tier 3, 4, and 6 Members Download Now
134 3,4,6 Designation of Primary and Contingent Beneficiary for Tier 3, 4, and 6 Members Download Now
136 ALL Supplemental Designation of Beneficiaries Download Now
137 ALL Designation of Guardian- When Designating a Minor as a Beneficiary Download Now
366 1 Selection by Designated Beneficiary of Benefits Under Option One Payable as an Annuity Under Option A Download Now
367 1 Selection by Designated Beneficiary of Benefits Under Option One Payable as an Annuity Under Option B Download Now
383 ALL Accidental Death Affidavit Download Now
501 2,4 Designation of Beneficiary - Post Retirement Lump-Sum Death Benefit Download Now

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SPECIAL PLAN OPT OUT FORMS
176 4,6 Opt Out Election Form- EMT Members Only >>> 25 Year Retirement Program for Tier 4 and 6 Download Now
177 4,6 Opt Out Election Form- Dispatcher Members Only - 25 Year Retirement Program for Tier 4 and 6 Download Now
186 4,6 Opt Out Election Form - Special Officer Titles 25 Year Retirement Program for Tier 4 and 6 Download Now
190 4,6 Opt Out Form - Police Communications Titles >>> 25 Year Retirement Program for Tier 4 and 6 Download Now
220 1,2 Withdrawal From Transit 20-Year Retirement Plan For Tier 1 and Tier 2 Members and Election of the Age Fifty Five One Percent Plan Download Now

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TRANSFERRING FORMS
 
232 ALL Transferred Contributor Affidavit - City University of New York (CUNY) Employees (ONLY for CUNY members who received a letter from NYCERS and who wish to remain NYCERS members as transferred contributors) Download Now
321 ALL Application for Transfer of Member's Accumulated Salary Deductions to Another Retirement System Within New York State Download Now
324 1,2 Election to Transfer Membership for Retirees of NYCERS Download Now

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BUY-BACK FORMS
 
237 ALL Request to Adjust Payment for the Purchase of Pre-Member or Military Service Download Now
238 ALL Request to Cancel Application For The Purchase of Pre-Member or Military Service Download Now
239 ALL Request to Cancel Current Pre-Member or Military Service Payroll Deductions Download Now
240 ALL Request For a Lump-Sum Payoff Balance For The Purchase of Pre-Member or Military Service Download Now
241 ALL Application to Purchase Credit for Service Rendered Prior to Membership Date in NYCERS Download Now
242 ALL Departmental Certificate of Status of Member Claiming Service Prior to Membership Date Full-time Service Only Download Now
245 ALL Application to Purchase Service Credit for Layoff Time
Department of Sanitation Uniformed Force
Download Now
246 1,2,3 Application to Purchase Service for Child Care Leave for Correction Members Download Now
247 ALL Agency Verification Download Now
248 ALL Application to Purchase Service for Layoff Time Download Now
249 ALL Application to Purchase Service Credit for Layoff Time for Carpenters & Supervisory Carpenters Download Now
250 ALL Application to Purchase Service Credit for Layoff Time for NYC Parks Department Climbers and Pruners Download Now
252 ALL Application to Purchase Service Credit for Layoff Time for Employees of the School Construction Authority Download Now

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BUY-BACK BROCHURES
901 ALL Buy-Back Brochure Purchasing Credit For Service Rendered Prior to NYCERS Membership Download Now

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MILITARY BUY-BACK FORMS
244 ALL Application to Purchase Credit for Military Service Download Now

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MILITARY BUY-BACK BROCHURES
902 ALL Buy-Back Brochure Purchasing Military Credit Download Now

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LOAN FORMS
301 1,2 Application for Loan (Tier 1 and Tier 2 Members Only) Download Now
302 3,4,6 Application for Loan (Tier 3, 4, and Tier 6 Basic and Special Plan Members) Download Now
303 1,2 Application for Loan Against Additional Member Contributions (AMCs) Download Now
305 ALL Authorization to Release NYCERS Loan Information (to accompany Deferred Comp Loan Application) Download Now
309 3,4,6 Application for Change in Loan Repayment Schedule Download Now
310 3,4,6 Request for Change to Recent Loan Application Download Now

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LOAN BROCHURES
912 1,2 Loans Brochure (Tier 1 and Tier 2) Download Now
911 3,4,6 Loans Brochure (Tier 3, 4, and Tier 6 Basic and Special Plan Members) Download Now

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LOAN FACT SHEETS
706 ALL Loan Taxability Fact Sheet Download Now
710 ALL Loan Default Fact Sheet Download Now
714 3,4,6 Loan Reduction Factors Download Now

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REFUND FORMS
331 ALL Application for Refund of Member's Accumulated Salary Deductions Download Now
332 1,2 Application for Refund of Excess Contributions Download Now
333 ALL Application for Refund of Additional Member Contributions Download Now
336 ALL Application for Refund of Additional Member Contributions For Transit 25 Year/Age 55 Members Download Now

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REFUND BROCHURES
913 ALL Refunds Download Now

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VESTING FORMS
251 1,2 Notice of Intention to File an Application for a Vested Retirement Benefit Download Now
254 3,4 Notice of Intention to File an Application for Payment of a Tier 3 or Tier 4 Deferred Vested Retirement Benefit Download Now
255 2 Application for Payment of a Reduced Vested Retirement Benefit Download Now
261 1,2 Application for Payment of a Vested Retirement Benefit Tier 1 and 2 Members (Except Corrections and Sanitation) Download Now
263 1,2 Application for Deferred Vested Retirement Allowance Tier 1 and Tier 2 Members of the Uniformed Force of the NYC Department of Correction Who Discontinue Service Other Than By Death, Retirement or Dismissal Download Now
265 4 Application for Payment of Vested Retirement Benefit Tier 4 Members with Tier 3 Rights Download Now
266 4 Application for Payment of a Tier 4 Deferred Vested Retirement Benefit Download Now
269 1,2 Application for Deferred Vested Retirement Allowance Tier 1 and Tier 2 Members of the Uniformed Force of the NYC Department of Sanitation Who Discontinue Service Other Than By Death, Retirement or Dismissal Download Now
283 3,4 Affidavit for Payment of a Vested Retirement Benefit Download Now
341 ALL Waiver of Right to a Vested Retirement Benefit Download Now

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VESTING BROCHURES
903 1,2 Vesting Tier 1 & Tier 2 Download Now
904 3,4 Vesting Tier 3 & Tier 4 Download Now

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LEAVING CITY SERVICE BROCHURE
908 4 Leaving City Service (for Tier 4 members in the 62/5, 55/25 and 57/5 plans) Download Now
POWER OF ATTORNEY
203 ALL Affidavit That Power of Attorney is in Full Force Download Now
204 ALL Special Durable Power of Attorney Download Now

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SERVICE RETIREMENT FORMS
511 1 Application for Service Retirement for Tier 1 Download Now
512 1 Application for Service Retirement for Tier 1 Members of the NYC Transit Authority Download Now
521 2,3,4 Application for Service Retirement for Tiers 2,3, and 4 Members Download Now
542 ALL Withdrawal of Service Retirement Application Download Now
543 ALL Request to Change or Correct Retirement Date Download Now
544 ALL Revision Form Download Now
595 1 Application for Without Fault or Delinquency Retirement Download Now

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SERVICE RETIREMENT BROCHURES
931 ALL Retirement Application Process Download Now

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RETIREMENT OPTIONS FORMS
550 1 Retirement Option 4-4 Tier 1 Members Download Now
551 1 Retirement Option Election Form for Tier 1 (Option 1, Option 4 – Lump Sum). Download Now
552 1,2 Retirement Option Election Form For Tier 1 and Tier 2 (Maximum, Option 2, Option 3, Option4-2,Option 4-3) Download Now
553 2 Retirement Option Election for Tier 2 (Option 4) Download Now
554 2,3,4 Retirement Option Election Form for Tier 2, Tier 3, and Tier 4 (5-Year and 10-Year Certain) Download Now
555 3 Retirement Option Election Form for Tier 3 (Maximum, Option 1, 2, 5) Download Now
556 4 Retirement Option Election Form for Tier 4 (Maximum, Option 1, 2, and 5) Download Now
557 1 Retirement Option 4 for Tier 1 Members Download Now
558 2 Retirement Option 4-4 for Tier 2 Members Download Now
559 2 Retirement Option 4 for Tier 2 Members Download Now
560 2 Selection by Beneficiary(ies) of a Tier 2 Member to Annuitize the Ordinary Death Benefit Download Now
561 1 Retirement Option Election Form for Tier 1 - Option 4 (Five-Year Certain; Ten-Year Certain) Download Now

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RETIREMENT OPTIONS BROCHURES
923 1 Options Brochure For Tier 1 Members Download Now
924 2 Options Brochure For Tier 2 Members Download Now
925 3 Options Brochure For Tier 3 Members Download Now
926 4 Options Brochure For Tier 4 Members Download Now

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DISABILITY FORMS
601 1 Application for Disability Retirement Tier 1 Members Download Now
602 2 Application for DisabiIity Retirement Tier 2 Members Download Now
603 3 Application for Disability Retirement Tier 3 Uniformed Correction Force Only Download Now
604 4 Application for Disability Retirement Tier 4 Members Download Now
605 ALL Applicant's Report of Personal Disability Download Now
606 ALL Physician's Report of Disability Download Now
607 ALL Agency Report on Accident Download Now
608 ALL General Authorization for Medical Information Download Now
609 ALL Questionnaire Applicants for Disability Retirement Download Now
611 3,4 Affidavit Electing to Process Disability Retirement Download Now
613 ALL Final Medical Review Waiver (To be completed by the Member) Download Now
614 ALL Waiver Pursuant to the Provisions of Article 14 of the Retirement and Social Security Law (RSSL) as it Pertains to Disability Retirements Download Now
618 ALL Consent of Disability Retiree to Report Personal Service Income* Each Year Download Now
619 ALL Withdrawal of Disability Retirement Application Download Now
622 ALL WTC Notice of Participation Download Now
623 ALL WTC Agency Report Download Now

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DISABILITY BROCHURES
921 1,2 Disability Retirement For Tier 1 & Tier 2 Download Now
922 3,4 Disability Retirement For Tier 3 & Tier 4 Download Now

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DISABILITY FACT SHEETS
703 ALL WTC Disability Law Fact Sheet Download Now

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PROCESSING DEATH BENEFITS
702 ALL Processing Death Benefits Download Now

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PROOF OF IDENTITY
711 ALL Proof of Identity
Download Now

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THE ROAD TO YOUR NYCERS RETIREMENT
716 ALL The Road to Your NYCERS Retirement Download Now

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BIRTH EVIDENCE
709 ALL Birth Evidence Alternatives Download Now
205 ALL Birth Evidence Affidavit Download Now

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PENSIONER SPECIFIC FORMS
349 ALL Application to Change Federal Income Tax Withheld Download Now
350 1,2 Safeguards Information Affidavit Download Now
351 3,4,6 Affidavit of Personal Service Income Download Now
352 ALL Election by a Retiree Reentering City Service to Rejoin NYCERS Download Now
353 ALL Certificate of Employment Under Section 212 of the Retirement and Social Security Law (RSSL) Download Now
354 ALL Affidavit of Workers' Compensation Payments Download Now
355 ALL Payroll Verification Affidavit Download Now
380 ALL Authorization for Direct Deposit (EFT) of Monthly Retirement Allowance Download Now
382 ALL Report of Beneficiary's Death - Pop-Up Option Elected Download Now

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PENSIONER SPECIFIC BROCHURES
958 ALL Earning Limitations For Service Retirees and Disability Retirees Download Now

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GUIDE TO YOUR PENSION CHECK
705 ALL Guide to Your Pension Check Download Now

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PENSION PAYMENT SCHEDULE
713 ALL Pension Payment Schedule Download Now

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REQUEST INFORMATION FORMS
852 ALL Request for Information Download Now

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CALCULATING FINAL AVERAGE SALARY BROCHURES
928 2 How To Calculate Your Final Average Salary Tier 2 Download Now
929 4 How To Calculate Your Final Average Salary Tier 4 Download Now

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CALCULATING RETIREMENT BENEFIT BROCHURES
927 4 Calculating Your Retirement Benefit For Participants in Tier 4 General Membership (62/5, 57/5, 55/25) Download Now
930 4 Calculating Your Retirement Benefit For Tier 4 Transit 25-55 Members Download Now

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LOST CHECK FORMS
399 ALL Affidavit Concerning Lost Check Download Now
ADDRESS CHANGE FORMS
290 ALL Change of Address Download Now

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NAME CHANGE FORMS
291 ALL Name Change Affidavit Download Now

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Forms Available By Mail

Form Tier(s) Form Name
201 ALL Affidavit to Waive Membership in the NYC Employees' Retirement System and to Elect Membership in the NYC Board of Education Retirement System
202 ALL Affidavit to Waive Membership in NYC Employees' Retirement System and to Elect Membership in the Teacher's Retirement System
210 1,2 For Tier 1 and 2 Members Only Election to Contribute Additional Contributions
211 1,2 Application to Restore Rate of Deduction
214 1,2 Election to Pay Extra Salary Deductions to Provide for Additional Annuity at Retirement
215 1,2 Revocation of Election to Pay Extra Salary Deductions to Provide Additional Annuity at Retirement
216 1 Request for Election or Change of Voluntary Contributions as Provided by the Transit 20 Year Non Contributory Plan
217 1,2 Election to Change the Present Method of Payment of Social Security Coverage
218 1 Affidavit for Retroactive Election to Reduce Annuity Contributions by the Amount Required to be Paid for Social Security Coverage
231 ALL Transferred Contributor Affidavit Board of Education (to be completed by member)