Form RS6400 "Retirement Option Election Form for Designating Multiple Beneficiaries" - New York

What Is Form RS6400?

This is a legal form that was released by the Office of the New York State Comptroller - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Office of the New York State Comptroller;
  • 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 fillable version of Form RS6400 by clicking the link below or browse more documents and templates provided by the Office of the New York State Comptroller.

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Download Form RS6400 "Retirement Option Election Form for Designating Multiple Beneficiaries" - New York

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Retirement Option Election Form
Received Date
For Designating Multiple Beneficiaries
RS 6400
Please type or print clearly
in blue or black ink
(Rev. 04/19)
Retirement System
[check one]
NYSLRS ID
Social Security Number
[last 4 digits]
Employees’ Retirement System (ERS)
XXX-XX-
Police and Fire’ Retirement System (PFRS)
MAKE NO ALTERATIONS TO THIS FORM. Please review carefully the options available and the instructions provided.
You must:
1. Elect a monthly benefit option by checking the appropriate box (page 1);
2. Sign and have the completed form notarized (page 2);
3. Return it promptly.
IMPORTANT: You must file your Option Election form before your pension benefit becomes payable, which is the first day of the month
following your retirement. You have up to 30 days after the last day of your retirement month to change your option selection. If your
election is not timely, by law, we must process your retirement as if you had selected the Single Life Allowance.
INFORMATION ABOUT YOU (Please make any needed corrections)
1. Name: (First, Middle Initial, Last)
2. Date of Birth:
3. Address: (Including Street, City, State and Zip Code)
TO THE COMPTROLLER OF THE STATE OF NEW YORK:
Year Certain
I elect to receive a reduced lifetime retirement allowance. If I die within my years
selection after my retirement date, continue paying my retirement allowance for the
5 Years
10 Years
remainder of the years to my beneficiary. If my beneficiary predeceases me, but I
also die within my years following my retirement, continue payments for the rest of
the period to another beneficiary I may name. If there is no surviving beneficiary,
make a lump sum payment to my Estate. If I die more than my years selection after
my retirement date, stop all pay ments at my death. (If you take this option, you
must also check the years you wish to be continued to your beneficiary.)
Electing An Option:
The option you elect is important to both you and your beneficiary. Be sure you understand the nature of each option, and elect the one
that best fulfills your needs. Also, be sure you have checked the proper box for the option that you wish to elect. On this form, you are
selecting a method of payment. When you have completed this form and have had it notarized, the original should be returned to:
New York State and Local Retirement System, 110 State Street, Albany, New York 12244-0001
We will acknowledge receipt of the option selection by sending you a letter.
Designating a Beneficiary:
Only one beneficiary may be named in a Joint Allowance or Pop-Up option. Under these options, proof of your beneficiary’s date of birth
must be submitted. If you wish to elect one of the Year Certain Options, you may designate more than one beneficiary. If you wish to do so,
please notify the Retirement System so we may send you the proper form for completion. If you elect one of the Year Certain Options, you
may designate your Estate as beneficiary. Under these options, you may change your beneficiary at any time. For each change of
beneficiary(ies), you must submit a form, which can be obtained from the Retirement System.
Information Services:
Information Representatives are available at consultation sites throughout New York State. To find the one nearest you, visit our website at
www.osc.state.ny.us/retire. You can also contact our Call Center toll-free at 1-866-805-0990 or 518-474-7736 in the Albany, New York
area.
Personal Privacy Protection Law:
The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide
information may interfere with the timely payment of benefits. The System may be required to provide certain information to participating
employers. The official responsible for record maintenance is the Director of Member and Employer Services, NYS and Local Retirement
System, Albany, NY 12244; call toll-free at 1-866-805-0990 or 518-474-7736 in the Albany Area.
RS 6400 (Rev. 04/19)
IMPORTANT – You must complete other side
(Page 1 of 2)
*04/18RS6400*
Retirement Option Election Form
Received Date
For Designating Multiple Beneficiaries
RS 6400
Please type or print clearly
in blue or black ink
(Rev. 04/19)
Retirement System
[check one]
NYSLRS ID
Social Security Number
[last 4 digits]
Employees’ Retirement System (ERS)
XXX-XX-
Police and Fire’ Retirement System (PFRS)
MAKE NO ALTERATIONS TO THIS FORM. Please review carefully the options available and the instructions provided.
You must:
1. Elect a monthly benefit option by checking the appropriate box (page 1);
2. Sign and have the completed form notarized (page 2);
3. Return it promptly.
IMPORTANT: You must file your Option Election form before your pension benefit becomes payable, which is the first day of the month
following your retirement. You have up to 30 days after the last day of your retirement month to change your option selection. If your
election is not timely, by law, we must process your retirement as if you had selected the Single Life Allowance.
INFORMATION ABOUT YOU (Please make any needed corrections)
1. Name: (First, Middle Initial, Last)
2. Date of Birth:
3. Address: (Including Street, City, State and Zip Code)
TO THE COMPTROLLER OF THE STATE OF NEW YORK:
Year Certain
I elect to receive a reduced lifetime retirement allowance. If I die within my years
selection after my retirement date, continue paying my retirement allowance for the
5 Years
10 Years
remainder of the years to my beneficiary. If my beneficiary predeceases me, but I
also die within my years following my retirement, continue payments for the rest of
the period to another beneficiary I may name. If there is no surviving beneficiary,
make a lump sum payment to my Estate. If I die more than my years selection after
my retirement date, stop all pay ments at my death. (If you take this option, you
must also check the years you wish to be continued to your beneficiary.)
Electing An Option:
The option you elect is important to both you and your beneficiary. Be sure you understand the nature of each option, and elect the one
that best fulfills your needs. Also, be sure you have checked the proper box for the option that you wish to elect. On this form, you are
selecting a method of payment. When you have completed this form and have had it notarized, the original should be returned to:
New York State and Local Retirement System, 110 State Street, Albany, New York 12244-0001
We will acknowledge receipt of the option selection by sending you a letter.
Designating a Beneficiary:
Only one beneficiary may be named in a Joint Allowance or Pop-Up option. Under these options, proof of your beneficiary’s date of birth
must be submitted. If you wish to elect one of the Year Certain Options, you may designate more than one beneficiary. If you wish to do so,
please notify the Retirement System so we may send you the proper form for completion. If you elect one of the Year Certain Options, you
may designate your Estate as beneficiary. Under these options, you may change your beneficiary at any time. For each change of
beneficiary(ies), you must submit a form, which can be obtained from the Retirement System.
Information Services:
Information Representatives are available at consultation sites throughout New York State. To find the one nearest you, visit our website at
www.osc.state.ny.us/retire. You can also contact our Call Center toll-free at 1-866-805-0990 or 518-474-7736 in the Albany, New York
area.
Personal Privacy Protection Law:
The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide
information may interfere with the timely payment of benefits. The System may be required to provide certain information to participating
employers. The official responsible for record maintenance is the Director of Member and Employer Services, NYS and Local Retirement
System, Albany, NY 12244; call toll-free at 1-866-805-0990 or 518-474-7736 in the Albany Area.
RS 6400 (Rev. 04/19)
IMPORTANT – You must complete other side
(Page 1 of 2)
*04/18RS6400*
Designation of Primary Beneficiary(ies).
Use the beneficiary’s give name. Mary Smith NOT Mrs. John Smith. Please print plainly or type.
I hereby name the following beneficiary(ies) to receive any benefit on my behalf. If I have named more than one beneficiary, it is
my intention that those living at the time of my death should share equally any benefit payable.
Male
Male
Name:
_______________________________________
Female
Name:
_______________________________________
Female
Address:
_______________________________________________
Address: ______________________________________________
______________________________________________________
_______________________________________________________
Relationship:
________________________
Birth Date:
___________
Relationship: ________________________ Birth Date:__________
Social Security Number:*
___________________________________
Social Security Number:*__________________________________
Male
Male
Name:
_______________________________________
Female
Name:
_______________________________________
Female
Address:
_______________________________________________
Address: _______________________________________________
_______________________________________________________
_______________________________________________________
Relationship:
________________________
Birth Date:
___________
Relationship: ________________________ Birth Date:___________
Social Security Number:*___________________________________
Social Security Number:*
___________________________________
Designation of Contingent Beneficiary(ies).
Use the beneficiary’s give name. Mary Smith NOT Mrs. John Smith. Please print plainly or type.
If all the above named beneficiary(ies) die before I do, any benefits payable on my behalf should be paid to the following: If I
have named more than one beneficiary, those living at the time of my death should share any benefit equally.
Male
Male
Name:
_______________________________________
Female
Name:
_______________________________________
Female
Address:
_______________________________________________
Address:________________________________________________
______________________________________________________
_______________________________________________________
Relationship:
________________________
Birth Date:
___________
Relationship: ________________________ Birth Date:___________
Social Security Number:*
___________________________________
Social Security Number:*___________________________________
Male
Male
Name:
_______________________________________
Female
Name:
______________________________________
Female
Address:
_______________________________________________
Address:_______________________________________________
______________________________________________________
______________________________________________________
Relationship:
________________________
Birth Date:
___________
Relationship:________________________ Birth Date:___________
Social Security Number:
*___________________________________
Social Security Number:* __________________________________
*Social Security Number required (See statement below)
Please sign your name in full below:
I certify that the information on my application is true and complete to the best of my knowledge. I further certify that I am aware that
any false statement I knowingly make or permit to be made on this or any record of the Retirement System constitutes a crime
punishable by potential incarceration and other sanctions.
Retiree’s Signature:__________________________________________________
Date:__________________________________
ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC
State of _______________ County of __________________ On the _____ day of _________________ in the year ________ before
me, the undersigned, personally appeared ___________________________________, personally known to me or proved to me on the
basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
NOTARY PUBLIC (Please sign and affix stamp)
*Social Security Disclosure Requirement: In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of your Social Security account
number is mandatory pursuant to Sections 11, 34, 311 and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the
administration of the Retirement System.
RS 6400 (Rev. 04/19) (Page 2 of 2)
Page of 2