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Withdrawal Application (RS5014)

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 . Membership ma y be terminated, but not befo re 30 day s after separation from service. Any loan balance whic h exis ts at the tim e of termination wil l be deducted from you r refund.

To make a change, draw a single line through the incorrect information, enter the updated information, and initial your change. To the Comptroller of the State of New York: I request that my membership in the retirement system be terminated and I apply for the return of contributions and interest credited on my account, if any.

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