Form F234 "Agency's Employee Status Change Notification" - New York City

What Is Form F234?

This is a legal form that was released by the New York City Employees' Retirement System - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the New York City Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F234 by clicking the link below or browse more documents and templates provided by the New York City Employees' Retirement System.

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Download Form F234 "Agency's Employee Status Change Notification" - New York City

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F234
NYCERS USE ONLY
*234*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Agency's Employee Status Change Notification
This form is to be completed by any agency to notify NYCERS of a status change for an employee who is ALREADY a NYCERS
member. Thank you for submitting this information; it will ensure that we update the member’s record and notify him/her of any
options.
THIS FORM MUST BE COMPLETED BY THE AGENCY ONLY
AND SIGNED BY THE AGENCY ON PAGE 2
EMPLOYEE INFORMATION
NYCERS Member Number
Last 4 Digits of SSN Title
Title Code
First Name
M.I.
Last Name
Address
Apt. Number
City
State
Zip Code
EMPLOYEE STATUS CHANGE
For the employee listed above, please complete the appropriate section:
[MM/DD/YYYY]
Resigned, terminated or was dismissed with an effective date of
/
/
.
Is on an approved leave for [check one]:
Medical
Child Care
Workers' Compensation
Union
Military Service
[MM/DD/YYYY]
[MM/DD/YYYY]
.
with an effective date from
/
/
to
/
/
Title change FROM:
Title Code
Title
TO:
Title Code
Title
[MM/DD/YYYY]
Reinstated and/or reassigned to previous status with an effective date of
/
/
.
Other [please specify]:
R02/17
Page 1 of 2
F234
NYCERS USE ONLY
*234*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Agency's Employee Status Change Notification
This form is to be completed by any agency to notify NYCERS of a status change for an employee who is ALREADY a NYCERS
member. Thank you for submitting this information; it will ensure that we update the member’s record and notify him/her of any
options.
THIS FORM MUST BE COMPLETED BY THE AGENCY ONLY
AND SIGNED BY THE AGENCY ON PAGE 2
EMPLOYEE INFORMATION
NYCERS Member Number
Last 4 Digits of SSN Title
Title Code
First Name
M.I.
Last Name
Address
Apt. Number
City
State
Zip Code
EMPLOYEE STATUS CHANGE
For the employee listed above, please complete the appropriate section:
[MM/DD/YYYY]
Resigned, terminated or was dismissed with an effective date of
/
/
.
Is on an approved leave for [check one]:
Medical
Child Care
Workers' Compensation
Union
Military Service
[MM/DD/YYYY]
[MM/DD/YYYY]
.
with an effective date from
/
/
to
/
/
Title change FROM:
Title Code
Title
TO:
Title Code
Title
[MM/DD/YYYY]
Reinstated and/or reassigned to previous status with an effective date of
/
/
.
Other [please specify]:
R02/17
Page 1 of 2
F234
NYCERS USE ONLY
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Member Number
Last 4 Digits of SSN
To report a NYCERS member who has transferred IN to your agency, please use Form #233.
AGENCY INFORMATION
Agency Name
Agency Bank Number
Personnel/Benefits Representative
Phone Number
E-mail Address
(
)
Signature of Personnel/Benefits Representative
Date
R02/17
Page 2 of 2
Page of 2