For Emergency Medical Technicians (EMTs) working within New York City or for the NYC Health & Hospitals Corporation, the NYCERS F170 form represents a critical step towards securing a future with enhanced retirement benefits. This document is designed for Tier 1, Tier 2, or Tier 4 members of the New York City Employees' Retirement System (NYCERS), providing them with the opportunity to elect participation in a 25-Year Retirement Program specifically tailored for EMT members. To be eligible, one must be an EMT member and adhere to specific conditions, such as joining after December 8, 2000, and filing the election form within 180 days of becoming an EMT member. This form, which necessitates notarization, outlines the understanding that once the election is made, it is irrevocable, underscoring the importance of careful consideration before submission. The document also includes space for updating contact information, ensuring that NYCERS can maintain accurate and current records. It’s a comprehensive resource for EMTs aiming to navigate their retirement options effectively, encouraging them to invest in their future by participating in this valuable program.
| Question | Answer |
|---|---|
| Form Name | Nycers Form F170 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | EMT, SSN, john murphy nycers, NYC |
NYCERS USE ONLY |
F170 |
|
*170*
Election of Optional EMT
Tier 1, Tier 2 or Tier 4 Members
This is an election for Tier 1 and Tier 4 members to participate in the
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 |
F170
Member Number |
Last 4 Digits of SSN |
|
|
I hereby elect to participate in the Tier 1 or Tier 4 Optional
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 |