Withdrawal Application (RS5014)

1 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.

2 Tier 1, 2, 3 & 4 members with five years of credited service have vested rights. Tier 3 & 4 members with more than five but fewer than ten years of credited service may terminate membership and forfeit their vested rights. (Membership cannot be terminated with ten or more years of credited service.) Tie r 5 & 6 members do not h av e vested right s unti l the y attai n ten or mo re year s of s ervice. ( Membership cannot be terminated wit h t en or mo re yea rs of credited service.) Before waiving your rights to a retirement benefit, you can use the Benefit Estimator on the portal homepage to estimate your future retirement benefit. If you have joined another retirement system operated by the State of New York or a political subdivision, you may be able to transfer your membership to that system. To do so, do not complete this form but complete the appropriate Application to Request to Transfer Membership.

3 By transferring your entire membership to another retirement system your contributions retain their tax-deferred status. You must initiate a transfer while you have active memberships in both systems. If you do not transfer when the privilege is available, you may not be able to get credit for this service at a later date. If you are a member of a retirement system in another state, we suggest you contact that system regarding the possibility of obtaining credit for your New York State service before you withdraw your membership. Trustee to Trustee Transfer Forms and Letters of Acceptance are available on your Portal Home Page. Print or type all Information and return to the address above. 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 St ate 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.

4 In consideration of the termination of my membership I hereby waive for myself, my heirs and assigns all my right, title, and interest in the funds of any and all benefits flowing from membership in the retirement system. I have terminated my employment and I am not now employed in any position in government se rvic e in which membership in thi s retirement system is available. I am a Tier 1, 2, 3 or 4 member credited with at least five years of service and understand that I am eligible for a future benefit. As a vested Tier 1, 2, 3 or 4 member, I could receive an estimate of my future benefits. By checking this box I am choosing to waive such estimate and that my Application be processed immediately. RS 5014 (Rev. 11/ 18)(Page 1 of 3) IMPORTANT You must complete other side *09/18RS5014* Information About You Name: (First, Middle Initial, Last) Former Name: (If applicable) Date of Birth: Address: (Including Street, City, State and Zip Code) Home Telephone Number: (Including area code) Work Telephone Number: (Including area code) Last Public Employer: Last Day Worked: (If known) Domestic Relations Order: (DRO) Will a current or pending Domestic Relations Order (DRO) or other legal document restrict any of your NYSLRS payment?

5 Yes No Citizen Status: For United States Tax Withholding and Reporting Purposes: (please check one), I am currently a: US Citizen Resident Alien Non-resident Alien If you are a Citizen or Resident Alien: This form will be used as a substitute IRS Form W-9. Under penalty or perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am writing for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from back withholdings; or (b) I have not been notified by theInternal Revenue Service (IRS) I am subject to backup withholding as a result of a failure to report all interest or dividends; or (c)the IRS has notified me I am no longer subject to backup withholding (You must cross out item 2 if you have been notified bythe IRS you are currently subject to backup withholding because you failed to report all interest or dividends on your taxreturn).

6 3. I am a Citizen/Resident Alien (defined in the instructions); and4. FATCA code(s) are not applicable due to NYSLRS exemption from FATCA Forms W-9 instructions are available on the website, you are a Non-resident Alien: You must complete and submit IRS Form W-8 BEN along with your Application . IRS Form W-8 BEN and instructions are available at the IRS website, and applications received without Form W-8 BEN will BE SUBJECT TO 30% WITHHOLDING. Payment Election: TAXABLE FUNDS (Check the appropriate payment box) NO ROLLOVER: I elect to have the taxable amount paid directly to me. I have read and understand the attached Tax Notice and understand that federal income tax will be withheld as required by law. ROLLOVER (Minimum transfer of $500. 00 if rolling to more than one institution). I elect to have the taxable amount of the payment transferred directly to an IRA, Roth IRA or other eligible retirement plan(s) as follows: Any remainder should be issued directly to me, minus any applicable federal withholdings.

7 (The enclosed trustee transfer form must be completed by both you and your trustee.) Institution: _____ Acct. #: _____ $ Amt. and/or %: _____ Institution: _____ Acct. #: _____ _____ $ Amt. and/or %:Institution: _____ Acct. #: _____ $ Amt. and/or %: _____ Non-Taxable Funds Non-taxable amounts will be paid directly to you, or If you wish to do a direct rollover of these funds, please contact our office for the appropriate applicationNote: All taxable funds must be rolled over if you want to rollover non-taxable funds. RS 5014 (Rev. 11/18) (Page 2 of 3) 30 Day Review Waiver: Because you are either receiving or rolling over money to a financial institution, you are entitled by law to a 30 day review period prior to NYSLRS processing the payment, which means this payment will not be processed until 30 days from the receipt of this Application . If you do not waive the 30 day review, you are acknowledging that you will receive your check greater than 30 days from the receipt of this Application .

8 I understand that under applicable law and regulations, I have the right to review this notice for 30 days. By checking this box I am choosing to waive such right. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. I certify that the information on my Application is true and complete to the best of my knowledge. I further certify that I am aware that any false statement I knowingly make or permit to be made on this or any record of the Retirement System constitutes a crime punishable by potential incarceration and other sanctions. Signature:_____ Date:Social Sec urity Disclosure Requirement In accordance wi th the Federa l Privacy Act of 1974 , yo u ar e hereby advised tha t disclosure of you r Social Security account number is mandatory pursuant to Sections 11, 34, 31 1 an d 334 of th e Retirement and Socia l Security Law.

9 Th e number wil l be use d in identifying retirement records and in the administration of the Retirement System. Personal Privacy Protection Law Th e Retirement Syste m is required by law to maintain record s to determine eligibility fo r an d calculate benefits. Failu re to provide information ma y interfere wi th the timel y payment of benefits. Th e System ma y be required to provide certain information to participating employers. Th e official responsible for recor d maintenance is the Director of Member an d Employer Services, NYS and Local Retirement System, Albany, NY 12244; call toll-free at 1-866-8 05-0990 or 518-474-7 736 in the Albany Area. RS 5014 (Rev. 11/18) (Pag e 3 of 3) Special Tax Notice Regarding Retirement SystemWithdrawal and Excess PaymentsRS 5533(Rev. (09/18)For Payments Not From a Designated Roth AccountYOUR ROLLOVER OPTIONSY ouarereceivingthisnoticebecauseallorapor tionofthewithdrawal/excesspaymentyouarer eceivingfromtheNewYorkStateandLocalRetir ementSystem(System),agovernmentaldefined benefitplan, GeneralInformationAboutRollovers SpecialRulesandOptions INFORMATION ABOUT ROLLOVERSH owcanarolloveraffectmytaxes?)

10 Anddonotdoarollover,youwillalsohavetopay a10%additionalincometaxonearlydistributi ons(unlessanexceptionapplies).However,if youdoarollover,youwillnothavetopaytaxunt ilyoureceivepaymentslaterandthe10%additi onalincometaxwillnotapplyifthosepayments aremadeafteryouareage59 (orifanexceptionapplies).WheremayIrollov erthewithdrawal/excesspayment?Youmayroll overthepaymenttoeitheranIRA(anindividual retirementaccountorindividualretirementa nnuity)oranemployerplan(atax-qualifiedpl an,section403(b)plan,orgovernmentalsecti on457(b)plan) ,fees,andrightstopaymentfromtheIRAorempl oyerplan(forexample,nospousalconsentrule sapplytoIRAsandIRAsmaynotprovideloans).F urther, (indirect) , (indirect)rollover, ,theSystemisrequiredtowithhold20%ofthepa ymentforfederalincometaxes(uptotheamount ofcashreceived).Thismeansthat,inordertor ollovertheentirepaymentina60-dayrollover ,youmustuseotherfundstomakeupforthe20% ,theportionnotrolledoverwillbetaxedandwi llbesubjecttothe10%additionalincometaxon earlydistributionsifyouareunderage59 (unlessanexceptionapplies).