Nycers Form F351 – Fill Out and Use This PDF

NYCERS USE ONLY	F351

*351*

Affidavit of Personal Service Income - 2012

Tier 3 or Tier 4 Disability Retirees

This form is to be completed annually by all Tier 3 & Tier 4 Disability Retirees. The purpose of this form is to verify your eligibility for continued disability benefits by reporting any Personal Service Income you received throughout the year. If NYCERS does not receive this affidavit, as well as the appropriate documents, your retirement benefit could be suspended until the information is received. Should you have any questions, please contact our Call Center at 347-643-3000.

First Name	M.I.	Last Name
Address				Apt. Number
City			State		Zip Code

Personal Service Income is considered to be any income, including income earned from both the public and the private sectors, you received for the year excluding the following:

-Your NYCERS’ Pension Check

-Social Security

-Workers’ Compensation

-Income earned from: rental property, stocks, bonds, IRAs and interest earned on deposits in bank accounts.

2.If you checked yes in question # 1, these monies you received are considered "Personal Service Income." Please calculate only your Personal Service Income for 2012 and place the amounts in the appropriate boxes below:

Sign this form and have it notarized, Page 2

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NYCERS USE ONLY	F351

Pension Number	Last 4 Digits of SSN

B. If you filed a Federal Income Tax Return for 2012, you must submit a copy of your Tax Return and your W-2 forms. If

you are married and filed a joint return, you must also submit a copy of your spouse's W-2 forms. If you did not file taxes for 2012, you still are required to submit copies of any W-2 forms you received.

I am including with this affidavit, the following:

A copy of my Federal Tax Return for the year of 2012 and my W-2 forms (if married and filed jointly please also include W-2 forms for your spouse).

I did not file my Federal Tax Return for the year of 2012 but I have attached my W-2 forms.

I did not file my Federal Tax Return for the year of 2012 and I have 0.00 Personal Service Income and no W-2 forms to submit.

To verify my eligibility for continued benefits, I have included the required documents with this affidavit.

Signature of Member	Date

Pursuant to The Penal Code of the State of New York, offering a document containing false statements or false information constitutes a felony punishable by a maximum of 4 years imprisonment. All documents suspected of containing false statements will be referred to The New York City Department of Investigation for investigation.

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.						If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission

Sign this form and have it notarized, THIS PAGE

R11/16/12

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