NYS Public Employees Federation Retirees

PENSION CHECK DEDUCTION AUTHORIZATION

(please print – instructions below)

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Last name                                                                             First name                                                                             MI

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Address                                                                  City                                                                        State                       Zip

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Social Security #                                                                                                  Retirement #

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Telephone

To: The Comptroller of the State of New York

Pursuant to §110 of the Retirement and Social Security Law, I hereby authorize deductions to be made from my monthly allowance from the NYS and Local Retirement Systems in the amount necessary to cover membership dues and/or insurance premiums payable on my behalf to the NYS Public Employees Federation Retirees. Authorization is also given to make any changes the union certifies to the Retirees System as necessary in the amount of such dues or insurance premiums. I understand that the NYS Public Employees Federation Retirees is my agent and all requests to begin, modify, or revoke deductions must be submitted through the union. This authorization shall remain in effect until revoked by me by written notice through the union or until otherwise revoked pursuant to law.

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Signature of Retiree                                                                                                                                            Date

Instructions

Social Security number and Retirement Number are required by the ERS in order to process this authorization. The Retiree Office does not share the Social Security number with any other organizations and does not print the Social Security number on any records or documents. It only appears on Computer screens when a record is displayed.

Retirement Number is provided in your final award letter from the ERS and is also on your pension check stub if you receive your pension by check. It is also shown on any pension change notices that you receive. If you can locate your Retirement Number, please write it in; if you cannot locate it, call the ERS at (518)474-4602 and ask them to provide you with your Retirement Number.

Revocation forms are available by calling the Retiree Office at (800)342-4306  ext.289

Completed forms should be mailed to:

PEF Retirees

1168-70 Troy-Schenectady Road  ●  P.O. Box 12414  ●  Albany, New York  12212-2414