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Get NY NYCERT Form 624 2019-2024

Complete this form in its entirety sign it have it notarized and send it to NYCERS at the mailing address above. NYCERS USE ONLY F624 Mail completed form to 30-30 47th Avenue 10th Fl Long Island City NY 11101 Application for Disability Retirement Tier 6 63/10 and Special Plan Members This application is for Tier 6 63/10 and Special Plan members who are applying for Disability Retirement. 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 Select a Benefit I am applying for check all that apply Disability Retirement RSSL 605 EMT Heart Bill GML 207-q EMT Performance-of-Duty Disability RSSL 607-b Deputy Sheriffs Accidental Disability RSSL 605-c List your Disabling Conditions The conditions listed on this form are the only conditions the Medical Board will consider under this application. Member Number First Name Last 4 Digits of SSN Home Phone Number Work Phone Number M. You must file this application while you are actually employed in the eligible title. 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. NOTE In addition to applying under the special disability provisions above Deputy Sheriffs and EMTs may also apply for Disability Retirement under RSSL 605 if they have 10 or more years of Credited Service. Withdrawal of Application Provided that NYCERS Medical Board has not yet finalized its findings you may withdraw your You may not withdraw an application filed by your agency on your behalf. Workers Compensation Payments Offset Disability retirement benefits under RSSL 605-c 607-b and GML 207-q are subject to an offset of 100 of any Workers Compensation payments received on account of the same injury for which the disability retirement benefits were approved. If you are approved for Disability Retirement no advance partial pension payment will be sent to you until NYCERS has acceptable proof of your birthdate on file. While you are on a leave of absence without pay for medical reasons either voluntarily or involuntarily OR 3. I the undersigned request to apply for Disability Retirement under the disability section s I marked on page 1. NOTE If the address you provide on this form is different from your address in our system the new address will become your official address in our records. I. Last Name Address City Apt. Number State Zip Code Title Agency Select a Temporary Option the date of your first full payment the Interim Period. If you select either the 100 Joint-and-Survivor or the Ten-Year Certain option you must name a beneficiary. Use your beneficiary s given name Mary Smith not Mrs. John Smith. Note You may not name your Estate for either the Joint-and-Survivor or the Ten-Year Certain benefit. evidence for your beneficiary is not required* CHOOSE ONLY ONE OPTION Maximum I elect to receive the maximum lifetime retirement allowance payable to me.

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