Form F623 "Agency Report Wtc Disability Law" - New York City

What Is Form F623?

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 December 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 F623 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 F623 "Agency Report Wtc Disability Law" - New York City

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F623
NYCERS USE ONLY
*623*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Agency Report
WTC Disability Law
This form is to be completed by the agency whose employee (or former employee) has filed a Notice of Participation with NYCERS
indicating that he/she participated in WTC Rescue, Recovery or Clean-Up Operations during certain qualifying periods between
September 11, 2001 and September 12, 2002. Please review all of the following questions and provide as much information as
possible. When you have completed the form, please send it along with any relevant supporting documentation to NYCERS.
Member Number (active or vested)
Pension Number (retiree)
Last 4 Digits of Social Security #
First Name
M.I.
Last Name
Using the attached Notice of Participation for reference, please answer the following questions:
1.
Y
N
Does the employee’s personnel record indicate that he/she had a physical examination upon
entry into public service?
2.
Participation in WTC Rescue, Recovery or Clean-Up Operations
The WTC law specifies various locations and activities, as well as different qualifying periods. Please
answer the questions [(A), (B), or (C)] that correspond with the information contained in the Notice of
Participation filed by the member, vested member, retiree or eligible beneficiary.
(A) Can you confirm that the member/vested member/retiree:
i) Participated in WTC Rescue, Recovery or Clean-Up Operations at the WTC site, the Fresh Kills Land
Y
N
Fill, the NYC Morgue or the temporary morgue on the pier locations on the west side of Manhattan, or
on the barges operating between the west side of Manhattan and the Fresh Kills Land Fill; and
ii) Participated in such operations at one or more of these locations for any period of time during the 48
Y
N
hours after the first airplane hit the towers or at least a total of 40 hours between September 11, 2001 and
September 12, 2002?
(B) Can you confirm that the member/vested member/retiree:
i) Participated in WTC Rescue, Recovery or Clean-Up Operations by repairing, cleaning or rehabilitating
Y
N
vehicles or equipment, including emergency vehicle radio equipment, owned by the City of New York
and contaminated by debris at the WTC site, regardless of where the work was performed; and
ii) Participated in such operations for any period of time during the 48 hours after the first airplane hit the
Y
N
towers or at least a total of 40 hours between September 11, 2001 and September 12, 2002?
R12/17
Page 1 of 2
F623
NYCERS USE ONLY
*623*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Agency Report
WTC Disability Law
This form is to be completed by the agency whose employee (or former employee) has filed a Notice of Participation with NYCERS
indicating that he/she participated in WTC Rescue, Recovery or Clean-Up Operations during certain qualifying periods between
September 11, 2001 and September 12, 2002. Please review all of the following questions and provide as much information as
possible. When you have completed the form, please send it along with any relevant supporting documentation to NYCERS.
Member Number (active or vested)
Pension Number (retiree)
Last 4 Digits of Social Security #
First Name
M.I.
Last Name
Using the attached Notice of Participation for reference, please answer the following questions:
1.
Y
N
Does the employee’s personnel record indicate that he/she had a physical examination upon
entry into public service?
2.
Participation in WTC Rescue, Recovery or Clean-Up Operations
The WTC law specifies various locations and activities, as well as different qualifying periods. Please
answer the questions [(A), (B), or (C)] that correspond with the information contained in the Notice of
Participation filed by the member, vested member, retiree or eligible beneficiary.
(A) Can you confirm that the member/vested member/retiree:
i) Participated in WTC Rescue, Recovery or Clean-Up Operations at the WTC site, the Fresh Kills Land
Y
N
Fill, the NYC Morgue or the temporary morgue on the pier locations on the west side of Manhattan, or
on the barges operating between the west side of Manhattan and the Fresh Kills Land Fill; and
ii) Participated in such operations at one or more of these locations for any period of time during the 48
Y
N
hours after the first airplane hit the towers or at least a total of 40 hours between September 11, 2001 and
September 12, 2002?
(B) Can you confirm that the member/vested member/retiree:
i) Participated in WTC Rescue, Recovery or Clean-Up Operations by repairing, cleaning or rehabilitating
Y
N
vehicles or equipment, including emergency vehicle radio equipment, owned by the City of New York
and contaminated by debris at the WTC site, regardless of where the work was performed; and
ii) Participated in such operations for any period of time during the 48 hours after the first airplane hit the
Y
N
towers or at least a total of 40 hours between September 11, 2001 and September 12, 2002?
R12/17
Page 1 of 2
F623
NYCERS USE ONLY
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Member Number
Pension Number
Last 4 Digits of SSN
(C) For the following communication/dispatcher titles in the NYC Police Department or NYC Fire Department only:
Department
Locations
Titles
New York City
11 MetroTech Center
Police Communication Technician (PCT), Supervisor Police
Police Department
(Brooklyn) or
Communication Technician (SPCT), Principal Police
1 Police Plaza (Manhattan)
Communication Technician I, Principal Police Communication
Technician II, Principal Police Communication
Technician III, Administrative Manager-Communications,
or in the Police Administrative Aide title series
35 Empire Boulevard (Brooklyn),
Fire Alarm Dispatchers (FAD), Supervising Fire Alarm
New York City Fire
79th Street Transverse
Dispatchers I (SFAD), Supervising Fire Alarm Dispatchers II
Department –
(Manhattan),
(Borough Supervisor), Deputy Director and Director of Fire
Dispatcher titles
83-98 Woodhaven Boulevard
Dispatch Operations or Assistant Commissioner for
(Queens), 1129 East 180 Street
Communications
(Bronx), 65 Slosson Avenue
(S.I.), 9 MetroTech Center
(Brooklyn) or 25
Rockaway Avenue (Brooklyn)
Emergency Medical Specialist-Level I (EMT), Emergency
Medical Specialist-Level II (Paramedic), Supervising
1 MetroTech Center (Brooklyn),
New York City Fire
Emergency Medical Specialist-Level I (Lieutenant),
9 MetroTech Center (Brooklyn)
Department –
Supervising Emergency Medical Specialist-Level II (Captain),
or 55-30 58th Street (Queens)
EMS titles
Deputy Chief EMS Communications or Division Commander
EMS Communications
Can you confirm that the member/vested member/retiree:
i) Participated in WTC Rescue, Recovery or Clean-Up Operations at one of the locations specified in the
Y
N
table; and
ii) Participated in such operations at one or more of these locations for any period of time during the 24
Y
N
hours after the first airplane hit the towers?
3.
If you answered “No” to any of the above questions [(A), (B), or (C)], please explain why in as much detail
as possible:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Date
Signature of Official
Print Name
Phone Number
Title/agency
PLEASE RETURN THIS COMPLETED FORM ALONG WITH ANY RELEVANT SUPPORTING DOCUMENTATION TO NYCERS.
R12/17
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