Get NY NYCERS F204 2021-2024

NYCERS USE ONLY F204 Mail completed form to 30-30 47th Avenue 10th Fl Long Island City NY 11101 New York Public Employee Retirement System Special Durable Power of Attorney This is a Public Retirement System Special Power of Attorney prepared pursuant to General Obligations Law Article 5 Title 15. This form has been prepared and circulated by the public retirement systems listed below as a convenience to their members retirees and beneficiaries. This form is limited to retirement benefit transactions involving those retirement systems and does not apply to any other matters. If you have any questions regarding this form please contact our Call Center at 347 643-3000. Member Number OR Pension Number Last 4 Digits of SSN Daytime Phone Number First Name M. I. Last Name a PURPOSE CLAUSE The purpose of this Power of Attorney document is to authorize my agent to act in my name place and stead with respect to retirement benefit transactions and my interest in benefits provided by one or more of the public retirement systems listed below pursuant to the Retirement and Social Security Law the Education Law and the Administrative Code of the City of New York as applicable. Please note By executing this special Power of Attorney without placing any limitations in Section g MODIFICATIONS you are authorizing your agent to conduct ANY transaction that you would be authorized to do discuss retirement benefits request access to personal information change depository account information etc* to the exclusion of naming him or herself as beneficiary. If you want your agent to be able to name himself/herself as the beneficiary or change your current beneficiary you must include this information in Section g MODIFICATIONS* A public retirement system for the purposes of this form shall include The New York State and Local Employees Retirement System The New York City Employees Retirement System b CAUTION TO THE PRINCIPAL Your Power of Attorney is an important document. As the principal you give the person whom you choose your agent authority to engage in retirement benefit transactions during your lifetime without telling you. You however do not lose your authority to act even though you have given your agent similar authority. When your agent exercises this authority he or she must act according to any instructions you have provided or where there are no specific instructions in your best interest. Important Information for the Agent at the end of this document describes your agent s responsibilities. PRINCIPAL - Sign this form and have it notarized Page 3 R12/16 Page 1 of 5 Your agent can act on your behalf only after signing the Power of Attorney before a notary public* You can request information from your agent at any time. If by executing this Special Power of Attorney you are revoking a prior authority with respect to retirement benefit transactions relating to an interest in any of the above-listed public retirement systems made under a previous Power of Attorney you should provide written notice of the revocation to your prior agent s and to any third parties who may have acted upon it including any appropriate public retirement system* You can revoke or terminate your Power of Attorney at any time for any reason as long as you are of sound mind* The subsequent incapacity of a principal shall not revoke or terminate the authority of an agent who acts under a durable power of attorney.