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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.

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

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