Member Forms
If you are retired, please go to the Retiree and Beneficiary Forms section.
Retirement Online now offers more services and time-saving features. In many cases, noted below, you can use Retirement Online instead of sending forms through the mail or calling NYSLRS. Because Retirement Online is a secure website, you may certify and submit your applications electronically instead of mailing in a notarized paper form.
Beneficiary Changes
Consider using Retirement Online to add or remove beneficiaries, or to update your beneficiary’s contact information.
To change your beneficiary information. Learn more about beneficiary changes.
(RS5127, Rev. 11/22)
Designation of Beneficiary — Trust
To designate a trust as either your primary or contingent beneficiary. This form is for active members only. If you are retired and receiving a pension (and have retired under payment option ½, 1, 5-Year Certain or 10-Year Certain), you should use the Pensioner’s Designation of Beneficiary form (RS6439).
(RS5127-T, Rev. 4/22)
Contact Information Changes
You can use Retirement Online to update your contact information and to choose to receive correspondence from NYSLRS by email.
To change your mailing address, email address and phone number.
(RS5512, Rev. 2/23)
To change your name.
(RS5483, Rev. 4/24)
Membership and Contributions
Consider using Retirement Online to reinstate an earlier tier of membership, transfer your membership, or withdraw from NYSLRS.
Tier Reinstatement Application
To reinstate a former membership in a public retirement system in New York State.
(RS5506, Rev. 9/22)
Transfer Membership Within NYSLRS
The Employees’ Retirement System (ERS) and Police and Fire Retirement System (PFRS) are the two separate systems that comprise NYSLRS.
Use this form to transfer a membership between these two retirement systems. Certain eligibility requirements apply. If you have questions, contact us before applying online or submitting the form.
(RS5535, Rev. 7/22)
Transfer Membership to Public Retirement System Outside of NYSLRS
To transfer your current NYSLRS membership out of ERS or PFRS, to another public retirement system in New York State. Certain eligibility requirements apply. If you have questions, contact us before applying online or submitting the form.
(RS5534, Rev. 8/20)
Transfer Back to ERS from PFRS
To reverse a transfer you previously made from ERS to PFRS. If eligible, this type of transfer will move all ERS salary, service and contributions that were formerly transferred to PFRS back to an ERS membership. Certain eligibility requirements apply. If you have questions, contact us before applying online or submitting the form. To qualify for this transfer, you must be currently covered by Section 384-d, 384-e or 381-b of the Retirement & Social Security Law (RSSL).
(PF5467, Rev. 12/09)
To withdraw your NYSLRS membership. If you have questions, contact us before applying online or submitting the form.
(RS5014, Rev. 5/22)
Election to Make Voluntary Contributions
For Tier 1 & 2 members (and Tier 3, 5 & 6 PFRS members who are non-contributory) who want to begin making voluntary contributions to NYSLRS for an annuity at retirement.
(RS5379, Rev. 6/21)
Cancellation of Election to Make Voluntary Contributions
For Tier 1 & 2 members (and Tier 3, 5 & 6 PFRS members who are non-contributory) who want to discontinue making voluntary contributions to NYSLRS.
(RS5378, Rev. 9/18)
Refund of Excess Contributions
For Tier 1 & 2 members (and Tier 3, 5 & 6 PFRS members who are non-contributory) who voluntarily contribute to NYSLRS to apply for a refund of their member contributions before retirement.
(RS5195, Rev. 4/22)
Member Death Benefits
Your survivors or employer should contact us to notify the Retirement System of your death so benefits can be paid to your beneficiary(ies), if applicable.
(RS6082, Rev. 5/22)
Non-member Employee Designation of Beneficiary for Eligible Employees of a New York State Agency
Due to eligibility requirements, this form is not available from our website. You must contact us to order a copy.
(RS6357)
Loans
When you use Retirement Online instead of completing and mailing a paper application, in most cases, you’ll receive your loan check much faster. You’ll see how much you can borrow and your payment options, and you’ll skip the need for a notary. You can also use Retirement Online to manage your loan payments, including increasing your payroll deductions and submitting a payment online.
Note: The following forms only apply to NYSLRS members. If you are a member of another public retirement system, please visit that system’s website for the appropriate forms.
For all Tier 1 and 2 members (ERS and PFRS) who have annuity savings member contributions on deposit with NYSLRS. Please make sure you read all pages and sign where necessary on page 3. We do not accept faxed loan applications.
Note: Please make sure this form prints properly with all text showing — especially in the Notary area — or the form may be rejected.
(RS5025, Rev. 4/22)
Tiers 3, 4, 5 & 6 Loan Application
For Tier 3, 4, 5 & 6 members (covered by Articles 14, 15 or 22). Please make sure you read all pages and sign where necessary on page 3. We do not accept faxed loan applications.
Note: Please make sure this form prints properly with all text showing — especially in the Notary area — or the form may be rejected.
(RS5025-A, Rev. 1/24)
To change the loan payment amount that is being deducted from your earnings by your employer.
(RS5521, Rev. 5/22)
Retirement — Service
Consider using Retirement Online to estimate your pension benefit and to apply for a service retirement.
Application for Service Retirement
This is a two-page form. Please submit both pages.
(RS6037, Rev. 2/23)
Withdrawal of Application for Service Retirement
(RS6354, Rev. 9/18)
This is a two-page form. Please submit both pages.
(RS6030, Rev. 12/23)
Retirement — Disability
If you are terminally ill, you will want to file a payment option election form along with your disability retirement application. For more information, please read Processing Your Application in our publication, Life Changes, Applying for Disability Retirement.
Article 14 Disability Retirement Application
For Tier 3 Employees’ Retirement System members and Tier 3 Police and Fire Retirement System members covered by Article 14 benefits. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6411, Rev. 11/22)
Article 14-B Disability Retirement Application
For county sheriffs, undersheriffs and certain deputy sheriffs whose employers elected coverage under Sections 555, 556, 557 or 558 of the Retirement & Social Security Law (RSSL). This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6408, Rev. 11/22)
Article 15 Disability Retirement Application
For Tier 3, 4, 5 and 6 members. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6340, Rev. 11/22)
605-A Accidental Disability Retirement Application
For court officers and peace officers in the Unified Court System. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6410, Rev. 11/22)
Environmental Conservation & Regional State Park Police Disability Retirement Application
For State Environmental Conservation and Regional State Park police officers covered by Section 363-e (RSSL). This is a two-page form and a HIPAA waiver. Please submit all three pages.
(PF6091, Rev. 11/22)
507-A Disability Retirement Application
For Tier 3, 5 and 6 NYS correction officers and security hospital treatment assistants. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6409, Rev. 11/22)
Ordinary Disability Retirement Application
For PFRS members and Tier 1 and 2 ERS members. This application is not for Tier 3 members covered under Article 14. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6038, Rev. 11/22)
Performance of Duty Disability Retirement Application
For NYS correction officers and security hospital treatment assistants who are covered by Chapters 653 and 722 (RSSL). This application is not for Tier 3 PFRS members covered under Article 14. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6047-A, Rev. 11/22)
Performance of Duty Disability Retirement Application
For sheriffs, deputy sheriffs, undersheriffs and county correction officers in counties that elected Sections 63-B, 63-C, 607C and 607D. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6047-B, Rev. 11/22)
Accidental Disability Retirement Application
For Police & Fire Retirement System members, Tier 1 and Tier 2 Employees’ Retirement System members and ERS members covered under Section 605-d and 607-e. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6047, Rev. 11/22)
Application for Police & Fire Retirement for disability incurred in the performance of duty and ERS members covered under Section 607-g and 89-v. This application is not for Tier 3 PFRS members covered under Article 14. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6442, Rev. 11/22)
State Police Disability Retirement Application
For Tier 1, 2, 5 and 6 members and officers employed by the Division of NYS Police. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(PF6090, Rev. 11/22)
Application for World Trade Center Notice
Notice of participation for those involved in the rescue, recovery or cleanup operations of the World Trade Center aftermath. The deadline for filing this notice has been extended to 9/11/26.
(RS6047-N, Rev. 6/23)
World Trade Center Accidental Disability Presumption Application
Application for disability retirement for those involved in the rescue, recovery or clean up operations of the World Trade Center aftermath. This is a two-page form and a HIPAA waiver. Please submit all three pages.
(RS6047-W, Rev. 11/22)
For beneficiaries of World Trade Center disaster victims. A beneficiary must file this application to convert a deceased retiree’s pension benefit to an accidental death benefit.
(RS6418-W, Rev. 12/23)
Authorization for Release of Health Information Pursuant to HIPAA
HIPAA forms must be submitted with all disability applications.
(RS6429, Rev. 9/18)
Option Election
Consider using Retirement Online to choose your pension payment option (option election) when you apply for a service retirement online.
Tier 1 Members who are choosing one option beneficiary
(RS6109-A, Rev. 12/04)
Tier 2 Members who are choosing one option beneficiary
(RS6163-A, Rev. 12/04)
Tier 1 Members who are choosing multiple option beneficiaries
(RS6268-A, Rev. 12/04)
Tier 2 Members who are choosing multiple option beneficiaries
(RS6352-A, Rev. 12/04)
Tier 3, 4, 5 and 6 Members who are choosing one option beneficiary
(RS6399, Rev. 12/23)
Tier 3, 4, 5 and 6 Members who are choosing multiple beneficiaries
(RS6400, Rev. 12/23)
Option Election with Partial Lump Sum Payment
Consider using Retirement Online to choose your pension payment option (option election) when you apply for a service retirement online.
These forms are for eligible Police & Fire members, county Correction Officers, Sheriffs, Undersheriffs and Deputy Sheriffs only. Eligible members must choose whether to receive a partial lump sum payment (a percentage of their pension value) in addition to choosing an option beneficiary.
Tier 1 Members who are choosing one beneficiary
(RS6419-A, Rev. 12/23)
Tier 2, 3, 5 and 6 Members who are choosing one beneficiary
(RS6421-A, Rev. 12/23)
Tier 1 Members who are choosing multiple option beneficiaries
(RS6420-A, Rev. 12/23)
Tier 2, 3, 5 and 6 Members who are choosing multiple option beneficiaries
(RS6422-A, Rev. 12/23)
Service Credit
Consider using Retirement Online to request previous or military service credit.
Request to Purchase Service Credit (Including any Military Service)
To request service credit for your public service before you became a member of NYSLRS, or to request credit for military service.
(RS5042, Rev. 12/23)
Application for Direct Trustee-to-Trustee Transfer for Purchase of Service Credit
To request the direct transfer of funds from a qualified plan in order to purchase optional or previously withdrawn service credit.
(RS2416, Rev. 6/15)
Change in Payroll Deductions for Service Credit Purchase
To change the service credit purchase amount that is being deducted from your earnings by your employer.
(RS5526, Rev. 5/22)
Special Retirement Plans
20-Year Retirement Plan (Section 384-d) Election Form
For Police & Fire Retirement System (PFRS) members whose employers have adopted this plan.
(PF5117, Rev. 2/23)
25-Year Retirement Plan (Section 384) Election Form
For PFRS members whose employers have adopted this plan.
(PF5095, Rev. 2/23)
Withdrawal from 25-Year Retirement Plan (Section 384)
Allows PFRS members who elected this plan to withdraw from it after one year of coverage.
(PF5094, Rev. 10/22)
Withdrawal from 20-Year Retirement Plan (Section 384-d and 384-e)
Allows PFRS members who elected this plan to withdraw from it after one year of coverage.
(PF5466, Rev. 10/22)
Election Form for 25-Year Retirement Plan for ERS Tier 3 Members (Sections 89, 603 and 604)
To be completed only by qualified Tier 3 members who are eligible to elect coverage under a special 25-year retirement plan as defined in Sections 89, 603 and 604.
(RS5473, Rev. 5/22)
To be completed only by sheriffs, undersheriffs, or deputy sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available.
(RS5495, Rev. 1/19)
To be completed only by sheriffs, undersheriffs, or deputy sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available.
(RS5496, Rev. 9/18)
To be completed only by sheriffs, undersheriffs, or deputy sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available.
(RS5497, Rev. 1/19)
To be completed only by sheriffs, undersheriffs, or deputy sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available.
(RS5498, Rev. 9/18)
To be completed only by sheriffs, undersheriffs, or deputy sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available.
(RS5498-A, Rev. 1/19)
To be completed only by sheriffs, undersheriffs, or deputy sheriffs directly engaged in criminal law enforcement 50% or more of the time, who are police officers under the criminal procedure act, and who are employed by a county which has elected to make these benefits available.
(RS5501, Rev. 1/19)
To be completed only by qualified security hospital treatment assistants, security hospital senior treatment assistants, security hospital supervising treatment assistants or security hospital treatment chiefs in Tier 3, 4, 5 or 6.
(RS5475, Rev. 5/22)
To be completed only by Tier 3 sheriffs, undersheriffs, deputy sheriffs and correction officers not already enrolled in a plan that permits retirement at any age after completing 25 years of service, and who are employed by a county which has elected to make these benefits available.
(RS5473-P, Rev. 5/06)
For PFRS Tier 3 members who want to elect coverage under Article 22 (Tier 5).
(RS5536, Rev. 9/18)
Retiree and Beneficiary Forms
Contact Information Changes
You can update your contact information using Retirement Online.
To change your mailing address, email address and phone number.
(RS5512, Rev. 2/23)
To change your name.
(RS5483, Rev. 2/23)
Death Benefits
Tier 2, 3, and 4 Post-Retirement Death Benefit Designation of Beneficiaries
Consider using Retirement Online to add or remove beneficiaries, or to update your beneficiary’s contact information. This paper form is to be used only for those already retired to change the beneficiary to receive their post-retirement death benefit. This form will be deemed invalid if received before your date of retirement. This beneficiary does not have to be the same as the retirement option beneficiary. This is a two-page form. Please submit both pages.
(RS4471, Rev. 11/22)
Pensioner’s Designation of Beneficiaries
To designate a beneficiary for when a retiree has selected a pension payment option that allows for beneficiary changes beyond the date of retirement (for example, the five- or ten-year certain option). It can also be used to designate a new beneficiary for the Survivor’s Benefit Program benefit if a retiree has selected the Single Life Allowance pension payment option, or if the pension payment beneficiary is deceased (please attach a photocopy of the beneficiary’s death certificate if we do not already have it on file).
(RS6439, Rev. 11/22)
Your survivors should contact us to notify NYSLRS of your death so benefits can be paid to your beneficiary(ies), if applicable.
(RS6082, Rev. 5/22)
Affidavit for Benefit Payment (1310.4)
To make a written statement for the purpose of receiving a deceased NYSLRS retiree’s death benefit when there is no executor, administrator of the deceased’s estate, surviving spouse, minor child, or beneficiary. This affidavit follows the provisions of Section 1310.4 of the Surrogate’s Court Procedure Act.
(RS4139, Rev. 5/22)
Pension Payments
Retirement Online is the quickest, most convenient way to adjust your federal withholding and update your direct deposit information. If you still receive your payment by mail, you can sign up for direct deposit through Retirement Online and get your money faster.
Electronic Funds Transfer Direct Deposit Enrollment Application
Use this form to have your monthly benefit electronically deposited to your checking or savings account. It can also be used to change your bank account information or the bank where your benefit is deposited. This is a two-page form. Please submit page 1.
(RS6370, Rev. 9/22)
Form W-4P Withholding Certificate for Pension or Annuity Payments
To adjust the federal income tax withholding that is deducted from your pension payment.
(RS4531, Rev. 12/22)
Estate Planning
Worksheet to help your survivors locate important documents/information upon your extended disability or death.
(VO1848, Rev. 2/19)
Employer Forms
Retirement Online Contact and Security Administrators
Employers who use Retirement Online need to have at least one employee who is designated as a Contact Administrator and at least one Security Administrator. For more information, please visit our Contact and Security Administrator Roles page.
Retirement Online Contact Administrator Authorization Form (Local Employers)
Use this form if you are a local employer who needs to add, remove, or replace a Contact Administrator.
(RS5544, Rev. 9/21)
Retirement Online Contact Administrator Authorization Form (State Employers)
Use this form if you are a State employer who needs to add, remove, or replace a Contact Administrator.
(RS5545, Rev. 9/21)
Retirement Online Security Administrator Authorization Form (Local Employers)
Use this form if you are a local employer who needs to add, remove, or replace a Primary or Alternate Security Administrator.
(RS5546, Rev. 9/21)
Retirement Online Security Administrator Authorization Form (State Employers)
Use this form if you are a State employer who needs to add, remove, or replace a Primary or Alternate Security Administrator.
(RS5547, Rev. 9/21)
Member Registration
Membership Applications now require that you enter a Job Code. The Code you assign indicates the work the employee does and, in part, determines retirement plan eligibility. Use this Job Codes Tool to ensure you are assigning the correct code.
Employees’ Retirement System Membership Application
To enroll new ERS members. This is a two-page form. Please submit page 1.
(RS5420, Rev. 12/23)
Police and Fire Membership Application
To enroll new PFRS members. This is a two-page form. Please submit page 1.
(PF5022, Rev. 11/22)
Monthly Salary & Service Certification
To certify a member’s previous employment.
Note: Overtime pay in excess of an annual cap is not included in the definition of salary for Tier 5 members and for Tier 6 members, and should not be included in the Monthly Gross Salary being provided on the form.
(RS5120, Rev. 4/22)
Reporting Employees
To establish a standard work day for employees who are not elected or appointed.
(RS2418, Rev. 5/22)
Reporting Elected and Appointed Officials
Standard Work Day and Reporting Resolution
For Elected and Appointed Officials
(RS2417-A, Rev. 12/23)
Standard Work Day and Reporting Resolution Continuation Form
For Elected and Appointed Officials
(RS2417-B, Rev. 4/20)
Recertification of the Record of Activities
For Elected and Appointed Officials
(RS2419, Rev. 6/22)
For more information about reporting requirements, review our Elected/Appointed Officials presentation.
Employee/Independent Contractor Certification Forms
Certification for Individuals Engaged in Certain Professions
For those hired on or after April 1, 2008.
(RS2414, Rev. 10/22)
Certification for Determining Independent Contractor or Employee Status
For those hired before April 1, 2008.
(RS2415, Rev. 10/22)
Monthly Reporting
The Adjustment Report form is used to make corrections to salary, service or contributions listed on previous monthly reports.
(RS2050, Rev. 8/23)
Adjustment Report for Pension Integrity Bureau
To make corrections to the salary and/or service listed on your employer report. Use this form if directed to do so by the NYSLRS Pension Integrity Bureau, as they will review it before processing.
(RS5527, Rev. 5/21)
Adjustment Report Label for Pension Integrity Bureau
Submit this form with the Adjustment Report for Pension Integrity Bureau.
(RS5528, Rev. 3/23)
Electronic Debit Authorization Form
To have payments for your NYSLRS members automatically debited from your account. With direct debit, funds are transferred electronically and securely using the automated clearing house (ACH) system.
(RS5542, Rev. 10/24)
To certify report information is correct and designate a security coordinator.
(Rev. 2/12)
Death Notifications and Benefits
You or your employee’s survivors should notify the Retirement System of their relative’s death so benefits can be paid to his or her beneficiary(ies), if applicable.
(RS6082, Rev. 5/22)
Notification of Death – Survivor’s Benefit Program
To notify the Retirement System of the death of your employee so any survivor benefits can be paid to his/her beneficiary(ies), if applicable.
(RS6358, Rev. 5/22)
Eligibility of Retired Employee for Survivor’s Benefit.
Note: This form is only to be used by New York State agencies and should be printed on legal (8½ by 14 inches) paper.
(RS6355, Rev. 3/14)
Retirement and Disability Related Forms
Statement of Accrued Payments and Leave Credits
To certify a member’s payments and credits. It must be submitted to NYSLRS before the member’s retirement can be finalized.
(RS6221, Rev. 4/22)
For Firefighters Paid Pursuant to Section 207-a of the General Municipal Law
To request retirement benefit information in order to determine the supplemental amount to be paid, pursuant to Section 207-a.
(PF6302, Rev. 9/22)
This form must be filed with and approved by the Department of Civil Service for retirees returning to work under Section 211.
(Rev. 8/16)
Order Forms and Publications
To order Retirement System forms and publications. For more information, visit our Order NYSLRS Forms and Publications for Employers page.
(RS1165, Rev. 3/18)
General Forms
Public Retirement System Special Power of Attorney Form
This form is limited to retirement benefit transactions and does not apply to any other matters. You can find information about authorizing an agent to act on your behalf on our Power of Attorney (POA) page.
(RS6450, Rev. 5/22)