Form F353 "Certificate of Employment Under 212 of the Retirement and Social Security Law (Rssl)" - New York City

What Is Form F353?

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, 2020;
  • 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 F353 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 F353 "Certificate of Employment Under 212 of the Retirement and Social Security Law (Rssl)" - New York City

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F353
NYCERS USE ONLY
*353*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Certificate of Employment
Under §212 of the Retirement and Social Security Law (RSSL)
This form is to be completed by retirees, other than disability retirees, who have reentered public employment in the City of New
York, or the State of New York or any of its political subdivisions, who wish to be covered by the provisions of RSSL §212. This
form is not to be completed by retirees who wish to rejoin NYCERS (such retirees need to file Form #352). Once filed, this form
applies to your entire period of post-retirement public employment. You may withdraw this form at any time. NOTE: If the address
you provide on this form is different from your address in NYCERS' system, the new address will become your official
address in NYCERS' records.
Pension Number
Last 4 Digits of SSN
Home Phone Number
Work Phone Number
(
)
(
)
First Name
M.I.
Last Name
Address
Apt. Number
City
State
Zip Code
[MM/DD/YYYY]
I am now employed by
effective
/
/
.
I, the undersigned, am a retiree. I have reentered public employment in the City of New York, or the State of New York or any of its
political subdivisions, and I do not wish to return to membership in NYCERS. I do wish to continue to receive my retirement
allowance without loss, suspension or diminution pursuant to §212 of the RSSL. I understand that my earnings from public
employment may not exceed $35,000* in calendar year 2020 and thereafter. I acknowledge that should my earnings in calendar year
2020 and thereafter exceed $35,000, my retirement allowance will be suspended in accordance with the provisions of §212 of the
RSSL.
I further understand that there will be no earnings limitation under the provisions of §212 of the RSSL during or after the calendar
year in which I attain age 65, unless I am an elected official who is subject to the provisions of Civil Service Law §150.
I acknowledge that if I have reentered public employment and am over age 65, I still have to file this form to be covered by the
provisions of RSSL §212 even though the earnings limitations may not apply to me.
I will notify NYCERS as soon as my earnings have exceeded the earnings limitation. I will submit to NYCERS a copy of my W2
form by February 15 of each year to verify my earnings in the previous year.
*This is the earnings limitation specified in §212 of the RSSL effective January 1, 2020. For previous years, the income limitation was
$30,000. It may be increased by an act of the New York State Legislature. Please consult the Legislation section of NYCERS' website
to see if legislation has been enacted to increase the limitation.
Signature of Member
Date
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
R02/20
Page 1 of 1
F353
NYCERS USE ONLY
*353*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Certificate of Employment
Under §212 of the Retirement and Social Security Law (RSSL)
This form is to be completed by retirees, other than disability retirees, who have reentered public employment in the City of New
York, or the State of New York or any of its political subdivisions, who wish to be covered by the provisions of RSSL §212. This
form is not to be completed by retirees who wish to rejoin NYCERS (such retirees need to file Form #352). Once filed, this form
applies to your entire period of post-retirement public employment. You may withdraw this form at any time. NOTE: If the address
you provide on this form is different from your address in NYCERS' system, the new address will become your official
address in NYCERS' records.
Pension Number
Last 4 Digits of SSN
Home Phone Number
Work Phone Number
(
)
(
)
First Name
M.I.
Last Name
Address
Apt. Number
City
State
Zip Code
[MM/DD/YYYY]
I am now employed by
effective
/
/
.
I, the undersigned, am a retiree. I have reentered public employment in the City of New York, or the State of New York or any of its
political subdivisions, and I do not wish to return to membership in NYCERS. I do wish to continue to receive my retirement
allowance without loss, suspension or diminution pursuant to §212 of the RSSL. I understand that my earnings from public
employment may not exceed $35,000* in calendar year 2020 and thereafter. I acknowledge that should my earnings in calendar year
2020 and thereafter exceed $35,000, my retirement allowance will be suspended in accordance with the provisions of §212 of the
RSSL.
I further understand that there will be no earnings limitation under the provisions of §212 of the RSSL during or after the calendar
year in which I attain age 65, unless I am an elected official who is subject to the provisions of Civil Service Law §150.
I acknowledge that if I have reentered public employment and am over age 65, I still have to file this form to be covered by the
provisions of RSSL §212 even though the earnings limitations may not apply to me.
I will notify NYCERS as soon as my earnings have exceeded the earnings limitation. I will submit to NYCERS a copy of my W2
form by February 15 of each year to verify my earnings in the previous year.
*This is the earnings limitation specified in §212 of the RSSL effective January 1, 2020. For previous years, the income limitation was
$30,000. It may be increased by an act of the New York State Legislature. Please consult the Legislation section of NYCERS' website
to see if legislation has been enacted to increase the limitation.
Signature of Member
Date
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
R02/20
Page 1 of 1