Tier 1
Affidavit of Workers’ Compensation Payments
Form #354
Use this affidavit to report Workers’ Compensation payments you have received, and/or are currently receiving.
Certificate of Employment Under Section 212 of the Retirement and Social Security Law (RSSL)
Form #353
File this form if you are a retiree who reenters public employment in the City or State of New York, and do not want to rejoin NYCERS. Pension payments will continue but your earnings may be limited.
Election by a Retiree Reentering City Service to Rejoin NYCERS
Form #352
This form is for retirees who are reentering City service and want to rejoin NYCERS. You will not be held to Earning Limitations set by §212 of the RSSL, but your current pension payments will be stopped.
Safeguards Information Affidavit
Form #350
This form is to be completed annually by all Tier 1 and Tier 2 Disability Retirees to verify your eligibility for continued disability benefits.
Birth Evidence Affidavit
Form #205
Submit this affidavit if you are unable to produce a birth certificate or any of the birthdate evidence documents accepted by NYCERS but can submit three alternative birth records. For a list of acceptable birthdate evidence, see NYCERS’ Birthdate Evidence Alternatives Fact Sheet #709.
Birthdate Evidence Alternatives
Fact Sheet #709
A list of alternative documentation that NYCERS will accept as evidence of birthdate if you cannot provide a legible, English-language birth certificate. Depending on the document(s) you provide, you may also be required to submit NYCERS’ Birth Evidence Affidavit #205.
Special Tax Notice Regarding Plan Payments
Fact Sheet #717
Tax consequences and rollover options when receiving a lump-sum payment from NYCERS.
Proof of Identity
Fact Sheet #711
An explanation of what documents NYCERS will accept from members, retirees, or beneficiaries as proof of their name (not proof of date of birth) or change of name.
WTC Agency Report
Form #623
This form is to be completed by the agency whose employee (or former employee) has filed a Notice of Participation with NYCERS indicating that he/she participated in WTC Rescue, Recovery or Clean-Up Operations during certain qualifying periods between September 11, 2001 and September 12, 2002.
WTC Notice of Participation
Form #622
NYCERS encourages all active, vested or retired members (retired after 9/11/01) who participated in WTC Rescue, Recovery or Clean-up Operations between September 11, 2001 and September 12, 2002 to file a Notice of Participation Form #622 before September 11, 2026.
Withdrawal of Disability Retirement Application
Form #619
If you previously filed for Disability Retirement and you now wish to withdraw that application, please complete this form in its entirety and return it to NYCERS.
Questionnaire – Applicants for Disability Retirement
Form #609
This application is to accompany your application for Disability Retirement.
General Authorization for Medical Information
Form #608
This form authorizes NYCERS to obtain medical information pertaining to those filing for disability.
Retirement Options – Tier 1
Brochure #923
This brochure describes the retirement options for Tier 1 members (members who joined NYCERS prior to July 1, 1973).
Retirement Option Election Form – Tier 1 – Option 4 (Five-Year Certain; Ten-Year Certain)
Form #561
This Retirement Option Election Form is for Tier 1 members who wish to elect the Five-Year Certain or Ten-Year Certain Option. By electing this option, you will receive a reduced retirement benefit. If you die within five (or ten) years from the date of retirement, the reduced monthly benefit will continue to be paid to the designated primary beneficiary for the unexpired balance of the five- (or ten-) year period.
Retirement Option Election Form – Tier 1 – Option 4
Form #557
Option 4 for Tier 1 members provides for a reduced lifetime monthly retirement allowance. Upon your death, a percentage of the reduced monthly allowance or a specific dollar amount will continue to be paid to your designated beneficiary. If you should die after the effective date of your retirement but before you receive your first full retirement payment, a benefit under Option 1 will be paid to your beneficiary. If you prefer that your beneficiary receive payment under Option 4 instead, you must initial the box on the form.
Retirement Option Election Form – Tier 1 – Option 1, Option 4 – Lump Sum
Form #551
This Retirement Option Election Form allows Tier 1 members to provide continuing income to their designated beneficiary(ies) upon their death, either as a Return of Reserve (Option 1) or a Lump-Sum Payment (Option 4). By electing a retirement option, you will receive a reduced lifetime retirement allowance.
Retirement Option Election Form – Tier 1 – Option 4-4
Form #550
This Retirement Option Election Form is for Tier 1 members who wish to provide continuing income to their designated beneficiary upon their death. Option 4-4 provides for a reduced lifetime monthly retirement allowance. Upon your death, a percentage of the reduced monthly allowance or a specific dollar amount will continue to be paid to your designated beneficiary.
Request to Change or Correct Retirement Date
Form #543
If you previously filed a Service Retirement Application with NYCERS, you may change your retirement date by filing this form with NYCERS up to the day before your effective retirement date. If your request is received on or after your retirement date, it is denied.
Note: You cannot change your retirement date if you are already receiving your pension from NYCERS.
Withdrawal of Service Retirement Application
Form #542
You may withdraw your Service Retirement Application by filing this form with NYCERS up to the day before your effective date of retirement. If your request is received on or after your retirement date, it is denied.