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Withdrawal Application (RS5014)

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Membership Withdrawal Application Received Date RS 5014 (Rev. 11/18) Please type or print clearly in blue or black ink NYSLRS ID Social Security Number [last 4 digits] retirement system [check one] Employees retirement system (ERS) XXX-XX-Police and Fire retirement system (PFRS) I am requesting to terminate my membership with the system selected below. Before filing this Application , please read the enclosed Tax information. Employees retirement system (ERS) Police and Fire retirement system (PFRS) Yo u do not become eligible fo r retu rn of y ou r contributions (if any ) unti l 15 day s afte r separation from service. If yo u hav e not mad e an y contributions, the re wil l be no payment due you.

Retirement System [check one] XXX-XX-Employees’Retirement System(ERS) Policeand Fire’ Retirement System(PFRS) I am requesting to terminate my membership with the system selected below. Before filing this application, please read the enclosed Tax information. ... GENERAL INFORMATION ABOUT ROLLOVERS

  General, Applications, System, Retirement, Withdrawal, Retirement system, Withdrawal application

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