NY Templates
Homepage ➨ Fillable Nycers F170 Form in PDF

Fillable Nycers F170 Form in PDF

Access This Form Online
Article Guide

The NYCERS F170 form is an important document for Emergency Medical Technician (EMT) members looking to secure their retirement benefits under specific programs. This form allows Tier 1 and Tier 4 members to elect participation in the 25-Year Retirement Program designed for EMTs, while Tier 2 members can opt for the Optional 25-Year Improved Retirement Program. To qualify, members must be actively employed as EMTs at the time of filing and must have joined the EMT membership after December 8, 2000. It is crucial to submit this election form within 180 days of becoming an EMT member to ensure its validity. The form requires personal information, including the member's name, contact details, and social security number, along with a signature that must be notarized. Once submitted, the election cannot be revoked, emphasizing the importance of careful consideration before signing. For those with questions, NYCERS provides a dedicated Call Center for assistance. Understanding the nuances of this form can significantly impact an EMT member's retirement planning.

Preview - Nycers F170 Form

NYCERS USE ONLY

F170

 

*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

Last 4 Digits of SSN

Home Phone Number

( )

Work Phone Number

()

First Name

M.I.

Last Name

 

 

 

 

 

 

 

 

Address

 

 

 

Apt. Number

 

 

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

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

R08/03/11

Page 1 of 2
If you have an official seal, affix it

F170

Member Number

Last 4 Digits of SSN

 

 

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

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This form must be acknowledged before a Notary Public or Commissioner of Deeds

 

 

 

 

 

 

 

 

 

 

 

 

 

State of

 

County of

 

 

On this

 

day of

 

 

2 0

 

, personally appeared

before me the above named,

 

 

 

 

 

 

, 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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sign this form and have it notarized, THIS PAGE

R08/03/11

Page 2 of 2
Get Nycers F170 PDF Form

Form Characteristics

Fact Name Description
Program Eligibility This form is for Tier 1 and Tier 4 members to join the 25-Year Retirement Program for EMT members and for Tier 2 members to participate in the Optional 25-Year Improved Retirement Program.
EMT Membership Requirement To participate, you must be an EMT member at the time of filing the application.
Filing Deadline The election form must be filed within 180 days of becoming an EMT member to be valid.
Previous Membership Option If you were an active EMT member on December 8, 2000, you could have joined this program by filing by June 6, 2001, but this option has expired.
Notarization Requirement The form must be acknowledged before a Notary Public or Commissioner of Deeds to be considered valid.
Contact Information For questions regarding the program, members can contact the NYCERS Call Center at 347-643-3000.
Revocation Policy Once NYCERS receives this election, it cannot be revoked.
Governing Law This form is governed by New York State law regarding retirement benefits for public employees.
Please rate Fillable Nycers F170 Form in PDF Form
4.73
Perfect
22 Votes

More PDF Templates

Nyc Doing Business Data Form - The inclusion of the entity type, principal officers, and owners who hold 10% or more stake is crucial for the form's integrity, underscoring the city's commitment to transparency in affordable housing dealings.

Medical Office Forms - Guidelines on ordering another person’s DMV records with respect to legal permissions.