*170*
Election of Optional EMT 25-Year Retirement Program
Tier 1, Tier 2 or Tier 4 Members
This is an election for Tier 1 and Tier 4 members to participate in the 25-Year Retirement Program for EMT members*, and for Tier 2 members to participate in the Optional 25-Year Improved Retirement Program. In order to participate in this program, you must be an EMT member at the time of filing this application. Please read the conditions below and complete the requested information. Should you have any questions regarding this program, please contact our Call Center at 347-643-3000.
Member Number |
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First Name |
M.I. |
Last Name |
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Address |
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I understand that in order for this election to be valid pursuant to law, I must:
1.have become an EMT member after December 8, 2000
2.file this election form within 180 days of becoming an EMT Member
If you were an active EMT member on December 8, 2000, you had the option of joining this program by filing this application by June 6, 2001; however, this option has since expired.
*EMT Member: A member of NYCERS while employed by the City of New York or the NYC Health & Hospitals Corporation in a title whose duties are those of an Emergency Medical Technician (EMT), or Advanced EMT (AEMT) or in a title whose duties require the supervision of employees whose duties are those of an EMT or AEMT
ONCE THIS ELECTION IS RECEIVED BY NYCERS IT CANNOT BE REVOKED
Sign this form and have it notarized, page 2
If you have an official seal, affix it
F170
Member Number |
Last 4 Digits of SSN |
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I hereby elect to participate in the Tier 1 or Tier 4 Optional 25-Year Retirement Program, or the Tier 2 Optional 25-Year Improved Retirement Program, and to contribute to NYCERS for the right to retire under this program.
Signature of Member |
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This form must be acknowledged before a Notary Public or Commissioner of Deeds |
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State of |
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On this |
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day of |
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, personally appeared |
before me the above named, |
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, to me known, and known to |
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she executed the same, and that the statements contained therein are true.
Signature of Notary Public or Commissioner of Deeds
Official Title
Expiration Date of Commission
HAVE YOU MOVED RECENTLY?
Old Address |
New Address (check box if same as on page 1) |
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Sign this form and have it notarized, THIS PAGE
