Form F604 – Fill Out and Use This PDF

NYCERS USE ONLY

F604

*604*

Application for Disability Retirement

Tier 4 Members

This application is for Tier 4 members who wish to apply for Disability Retirement. Before you complete this application, be sure to read the TERMS section on page 4.

In addition to this application, you must also submit (to NYCERS' Medical Board):

•Applicant’s Report of Personal Disability (Form #605) • General Authorization for Release of Medical Information (Form #608)

• Physician's Report of Disability (Form #606)

• NYCERS Questionnaire (Form #609)

Should you have any questions, please contact our Medical Unit at 347-643-3000.

Select a Benefit:

Please mark the disability sections that apply to you. You may be eligible to apply for more than one benefit. I am applying for:

Disability Retirement under the World Trade Center Law (see WTC Fact Sheet for more information)

RSSL = Retirement and Social Security Law GML = General Municipal Law

EMT = Emergency Medical Technician

Member Number

Last 4 Digits of SSN

Home Phone Number

Date of Birth [MM/DD/YYYY]

(

)

/

/

First Name

M.I.

Last Name

Address

Apt. Number

City

State

Zip Code

Agency

Title

Federal Tax Withholding

Federal tax law provides that all payers are required to withhold Federal income tax on periodic payments (similar to wages), unless you elect to be excluded from such withholding. This election will remain in effect until revoked by you. If you do not complete this election, Federal income tax will be withheld at the rate of a married individual claiming three exemptions.

Please indicate your withholding selection by marking the appropriate choice below:

Note: You cannot enter an amount here without entering a number of exemptions in choice 2 (even if that number is zero).

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Member Number	Last 4 Digits of SSN

Select an Interim Option: This section allows you to select an Interim Option (temporary option). Selecting an Interim Option protects you and your beneficiary(ies) during the period between your retirement date and the date you make a final option selection. It enables you to leave some form of your pension payment to whomever you designate on page 3 of this application should you die before a final option selection is made and your pension is finalized. You may choose to be temporarily covered by one of the options listed below.

If you do not select an Interim Option and you die before your pension is finalized, it is assumed that you selected the Maximum Retirement Allowance and your pension will not continue upon your death.

Option 1 -- 100% Joint-and-Survivor:

Option 1 is a reduced benefit that is payable to you for your lifetime. It guarantees that the same reduced benefit will continue to your surviving designated beneficiary for life. Payments cease upon the death of both you and your beneficiary.

Option 2 -- 75%/50%/25% Joint-and-Survivor:

Option 2 is a reduced benefit that is payable to you for your lifetime. It guarantees that a percentage of your retirement allowance will be payable to your designated beneficiary for his or her lifetime. Your beneficiary will receive 75% or less (in 25% increments) of the reduced benefit paid to you. All payments cease after the death of both you and your designated beneficiary.

Option 3 -- Five-Year Certain:

Option 3 is a reduced benefit that is payable to you for your lifetime. If you die within five years from the date of retirement, the reduced benefit will continue to be paid to your Primary Beneficiary for the unexpired balance of the five-year period. If your Primary Beneficiary predeceases you, the payments due for the remainder of the five-year period are continued to your Contingent Beneficiary (if there is one) upon your death. If none exists, the balance is paid in a lump sum to your estate. Should your Primary Beneficiary die after having started to receive payments, the balance will be paid in a lump sum to your Contingent Beneficiary. If none exists, the lump-sum balance is paid to the estate of your Primary Beneficiary. Unlike Options 1 and 2, you may change your beneficiary(ies) with this option, but only within five years from the date of retirement.

Option 4 -- Ten-Year Certain:

Option 4 is a reduced benefit that is payable to you for your lifetime. If you die within ten years from the date of retirement, the reduced benefit will continue to be paid to your Primary Beneficiary for the unexpired balance of the ten-year period. If your Primary Beneficiary predeceases you, the payments due for the remainder of the ten-year period are continued to your Contingent Beneficiary (if there is one) upon your death. If none exists, the balance is paid in a lump sum to your estate. Should your Primary Beneficiary die after having started to receive payments, the balance will be paid in a lump sum to your Contingent Beneficiary. If none exists, the lump-sum balance is paid to the estate of your Primary Beneficiary. Just like Option 3, you may change your beneficiary(ies) with this option, but only within ten years from the date of retirement.

Option 5 -- 100% or 50% Pop-up:

Option 5 is a reduced benefit that is payable to you for your lifetime. Under this option, your designated beneficiary will receive the benefit payable under the 50% or 100% joint-and-survivor option (see Option 1 or Option 2). However, should your designated beneficiary predecease you, your retirement allowance will "pop up" to the Maximum Retirement Allowance for the remainder of your life. All payments cease upon your death.

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F604

Member Number	Last 4 Digits of SSN

If this beneficiary is a minor, check here and complete the guardian information on Form 137

If you have chosen the Five-Year Certain Option or Ten-Year Certain Option, please also designate a Contingent Beneficiary below.

Should my Primary Beneficiary die before the five-year period or ten-year period expires, respectively, the Contingent Beneficiary whom I nominate is:

If this beneficiary is a minor, check here and complete the guardian information on Form 137

I, the undersigned, request to apply for Disability Retirement under the disability section(s) I marked on Page 1.

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

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Member NumberLast 4 Digits of SSN

TERMS

Filing Requirements for RSSL §605 and RSSL §605-b

You must file an application for a Disability Retirement Benefit:

1. within three months from the last date you were being paid on the payroll, OR

2.while you are on a leave of absence without pay for medical reasons, either voluntarily or involuntarily, OR

3.no later than 12 months after the date you receive notice that your employment has been terminated, provided that you were on an approved leave of absence without pay for medical reasons, which was in effect immediately prior to such termination.

The application must be filed by you, or by a person with legal authority to act on your behalf, or by the head of the agency where you are employed.

Disability Retirement (RSSL §605):

If you have 10 or more years of Credited Service and NYCERS’ Medical Board determines that you are unable to perform the duties of your job title due to a physical or mental impairment, you are eligible to receive a Disability Retirement Benefit. If you have less than 10 years of Credited Service and NYCERS’ Medical Board determines that you are disabled as a natural and proximate result of an accidental injury sustained in City service, not caused by your own willful negligence, you are eligible to receive a Disability Retirement Benefit.

Uniformed Sanitation ¾ Accidental Disability (RSSL §605-b):

A Uniformed Sanitation member is eligible to apply for Accidental Disability if he or she becomes incapacitated for the performance of duty as a natural and proximate result of an accidental injury sustained in service while a Uniformed Sanitation member, not caused by his or her own willful negligence. Application must be made within two years after the occurrence of the accident.

Uniformed Sanitation Heart Bill (GML §207-r):

The Heart Bill provides a presumption that a disease of the heart was incurred in the performance of duty. Uniformed Sanitation members who are approved for disability under the Heart Bill are entitled to an Accidental Disability Benefit. The presumption may be rebutted by competent medical evidence.

Filing Requirements for RSSL §§605-c, 607-b and GML §207-q

You must file this application while you are actually employed in the eligible titles (Deputy Sheriff, EMT).

Deputy Sheriffs ¾ Accidental Disability (RSSL §605-c):

NYC Deputy Sheriffs who become physically or mentally incapacitated for the performance of duties as the natural and proximate result of an accident, not caused by their own willful negligence, are entitled to an Accidental Disability Benefit.

EMT ¾ Performance-of-Duty Disability (RSSL §607-b):

EMTs who become incapacitated for the performance of duties on or after March 17, 1996 as the natural and proximate result of an injury sustained while employed as an EMT are entitled to a Performance-of-Duty Disability Benefit. You may also apply under this section if you are presumed to have contracted HIV (through the bodily fluids of a person under care), tuberculosis or hepatitis while in the performance of your duties.

EMT Heart Bill (GML §207-q):

The Heart Bill provides a presumption that a disease of the heart was incurred in the performance of duty. EMTs who are approved for disability under the Heart Bill are entitled to a Performance-of-Duty Disability Benefit. The presumption may be rebutted by competent medical evidence.

NOTE: In addition to applying under the special disability provisions above, Uniformed Sanitation members, Deputy Sheriffs and EMTs may also apply for Disability Retirement under RSSL §605 if they have 10 or more years of Credited Service.

World Trade Center (WTC) Disability Law

The World Trade Center (WTC) Disability Law provides a presumption of accidental disability for NYCERS members who participated in WTC Rescue, Recovery or Clean-Up Operations and become disabled from a Qualifying Condition or Impairment of Health. Benefits are paid according to the provisions that cover accidental disability for your tier and title. For complete details and eligibility requirements, please read our WTC Disability Law Fact Sheet #703, available on our website at www.nycers.org.

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