Preview
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
"6"
EXHIBIT
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
usLas snar==a copy page 1 or 6
OfficeoftheNewYorkStatoComptroller
ThomasP.OINapoli
New YorkstateendLocafRetirementSystem
Employees'RetirementSystem
PoliceandFireRetirementSystem
12244-000'
110Statestreet,Albany,NewYork
Phone:1-866-80049900-618-474-7736 Far518-402-4433
E-mail:nyslrsinfo@osc.stateny,us
Web;wnwoac.state.nyus/ralira
December 27, 2013
Marianne F Kelly In reply refer to
41 Easy St Reg. No.: 50667500
Hurley NY 12443
Dear Member:
Our records indicate that you are no longer working for a public employer
that participates in this Retirement System. Since you are not eligible
for a retirement your- in this Retirement System will
benefit, membership
terminate for inactivity on October 31, 2019, unless you return to public
employment with a participating employer before then. Public employment is
paid service with New York State, a county, city, town, villa ge, school
district or public authority.
I f you are currently in public employment, please contact us immediately.
If your employment is covered by this Retirement System, we must update
your status .
If you are now a memner or another New York State Retirement system, you
may be eligible to transfer your membership and service credit from this
system to your current system. (When you contact us, we will provide you
with additional information and forms if this applies to you.
You currently have $7.97 on deposit with us. You may withdraw
these funds at any time, by completing the enclosed Withdrawal Application
and returning it directly to us at the above address . It will not be
necessary for you to have the employer certification completed.
If yo·u have an outstanding loan balance when we process your Withdrawal
Application, we will deduct the amount of your loan, unpaid interest, loan
insurance premiums and federal taxes, if applicable.
If you do not withdraw, your funds will remain on deposit and continue to
earn interest until your membership teminates, as mandated by law. Please
notify us of any change in your mailing address to ensure you receive your
annual member statements and other important correspondence. If you return
to public employment before your membership terminates, you will resume
earning credit toward your retirement.
S- v20
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
YSLRs S==M Copy page 2 of 6
Once our membership terminates, interest will no longer accrue on your
contr ution balance or on any outstanding loan balance, and your
contribut ions will be reduced by any remnaining loan balance. Any loan
balance amount not previously taxed will be reported to the Internal
Revenue Service in the year your membership terminates, and may be subject
to federal tax withholding.
Whether your membership terminates due to inactivity or through your
voluntary withdrawal, if you later re-enter public employment, and become a
member of a public Retirement System in New York State, you may apply for a
reinstatement to your previous tier and date of membership.
I f you have any questions, you may contact us toll -free at 1-866-805-0990
(or 518-474-7736 in the Albany, New York area), or write to us at the above
address.
Sincerely ,
John Wheeler
Employees' Retirement
System Examiner V
Member & Employer Services
JW/ABC966 MAB18
Enc.
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
Mshits sma-1 copy page 3 of a
Office of the New York State Compt-oller
Thomas P, DINapoll
"7mY k.Sat d oc ant Snt"
Withdrawal Application
Polloe and Fire Retirement
System
PIO State Street
Albany, New York12244-0001
Phone: 1-866-805-0990 or St 8-474-7736
Fax: 516-402-4433
heb·
E-mail: nyslrsinfo@osc,state.ny.us
www.osc.state.ny.ustretire RS 6014L-6 (Rev 05/11)
This form Is for terminating
your membership In the New York State and Local Retirement Systems.
Please read the following:
You do not become eligible for retum of your contributtons (if
any) until 15 days after separation ftom service.
If you have not made any contributions, there will be no payment due you.
Membership may be terminated, but not before 30 days ofter separation tom
sendee
Any toan balance which codstsat the time of terrnination will be deducted itom your refund.
Ter 1, 2, 3 & 4 membere with five years of created
service how
vested rits. Tier 3 and 4 members with more than five but fewer than ten years of
cred1ed service rnay terminate membership and forfeit their vested dghts.
Nor 5 members do nol have vested rights until they attain ten or more years oIservice.
Generally, membershp cannd be terminated If a member has vested rights and ten or more years of credited sendce.
Ifyouhave joined andher retirement system operated by the State of New York or a paltical
subdivision, you may be able to transfer your membership to
that system. Tb do so, do not complete this form but send for form RS 5223, Request to Transfer
Membership, By transferring your entire membership to
another retirement system your contributions retain their tax-deferred status. If you do not transfer
when the prMlege
la avalfable, you may not be able
to get credit
for this service d
a later date.
This section
to be completed
by Member
- Cornplete (print or type) Items 1 - 6 below You
Instructions MUST SION the declaration, in nk. You MUS_ _choosea payment option on the lower half of
this form.
To the Comptroller
of the 8tate of New York:
I request that my membership
In the retirement system be terminated
and I apply for the retum of cenbibutions and nterest credited on my account4
in conskieraUon d the terrnination of my membrship I hereby waive for myself, my heira and assigns all any
my right, title, aMInterest
in the funds of any and
all benefits flowing from merrtership
In the retirement system. I have terminated my employment and I am not now employed in
position
any ingovemment
service in which Inembership in this retirement system is avaltable.
O I am a ¶er
1, 2, 3.or 4 member credited with at least 1ve years of service and understanc|that I am eligible for a future benefit. As a vested Tier
1, 2, 3
or 4 member, I could receive an estimate of my tuture benefits. By diecleng this box I am
choosing to waive such estimate and that my application be
processed irnmediately.
1. Name Phrase pmvkfe e telephone number where you can be reached
during the day. This ww only be used H mere ore quesflons which
2. Social Security Number" may delay the processing of your applic.ation.
3. t.ast Public Employer
(Area Code)TesephoneNumber
4. Last Day Worked, if Known
5. Registration Number
6. Date of Birth
Monm Day Year
7. Your home address· -
Sheet Chy Siste Zip Code
8. Payment Election
Please indicate your choice donly
one of the fdlesing
payment options:
I have read the information regardag federal tax withhdding and rolfovers d the distrhution payaNe to me. I elect to receive the entire
distrbution
rather than reling over ell or part of the taxable portion of such distrbution to a quallted plan or IndMdual retirement account. I understand that
Federal law requires that twenty percent of the taxable portim
d such distribution wiNbe wthheld fcr laxes pursuant to the Internal Revenue Code
and epplicable regulations. I further
understand that under applicable
law and regulations,
I have the sight to review this notice
for 30 days
priorto making this election,
and hereby waive such right
O Ihave read the Inforrnation regardng federal tax withholding and rat overs of the astribution payable to me. I eled to receive the entire distrbution
rather than rcilog over all or part of the taxable portlan of such distribution to a quallAedplan or individual retirement account. I understand that
Federal law requires that twenty percen1of the taxable portion of such distributlan wltl be wthhold Item the payment, pwsuant to the Internal Revenue
Code and applicable regulations. I further
understandthat I have the rl
t to review thle notice
for 30 days prior to the processing
of my
reftmdand that during that period no pay ment will be made.
O I have read the Information regardng federal tax withholdng and reliaters of the dshibution
payable to me. I elect to rollover the taxabkr portion of
such distribution to a qualllied plan or individual retirernent account as indicated on the Trustee-to-Trustee section d
this application.
Signature Date
Please go toback of thisform formore information
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
rYSLRS Saanned Copy page 4 of d
RS6014(Rev05h1) Page2
SPECIAL TAX NOTICE REGARDING REEREMENT SYSWM WITHDRAWALS
This notice contains Important information you wtil need before you decide how to receive your wthdrawal payment from the New York State and Local
Retirement Systems.
SUMMARY
Awithdrawalpayment from the Retirement System consists of a taxable amount, and may also include a non-taxable amount. The taxable amount eligible
for "rollover" can be taken In one of two ways. You may have at cr any portion of your taxable payment either 1) PAID LNA 'DIRECT ROLLOVER'or
your Individual retirement arrangement (IRA) or to
2) PAID TO YOU. A rolloweris a payment of the taxabte portion of your Retirement System withdrawal to
another employer plan. This choice will affect the tex you owe.
If you choose a DIRECT ROLLOVER:
a Your rehmd wit not be taxed in the curent be withheld.
year and no Income tax w)
a Your refund will be made directly to your IRA or, :fyou choose, to another employer plan that accepts your rdlover.
a Your refund wm be taxed Inter when you take It cut of the IRA or the employer plan.
If you choose to have your Retirement System withdrawal PAID TO YOU:
- 20% of the taxable
You will receive only 60% of the taxable portion of the refund because the Retirement System Is required to wthhdd
portion of the refund and send t to the IRS as Income tax withholding to be credited against your taxes.
* Your payment wit be taxed h the current year unless you roll it over. You may be able to use special tax rules that could reduce the tax
10% tax.
you owe. However, If you receive the refund before age 55, you also may have to pay an addtlenal
The
a You can roll over the payment to your IRA or to another employer plan that accepts your reitcver within 60 days of receiving the payment.
amount rolled o/or will not be taxed until you take t cut of the IRA or the other employer plan.
a If you went toroll over 100% ofthe
payment toan employer plan, you must lind other money to replace the 20% that was withheld.
IRA or andhar
If you roll over only the 80% that you received, you will be taxed on the 20% that was withheld and is not rdled over.
MORE INFORWIAMON
1, PAYMENTSTHAT CAN AND CANNOT BE ROLLIEDOVER dstributions." This means that
Payments trom the Retirement System may be "eligible rdlover they can be rolled over to an IRA or to another
employer plan that accepts rollovers. The Retirement System will tag you what portion of your payment is an eligible rollowerdistifoution, The
followhg types of payments cannot be refled over:
portion" of your payment is an elldble rollover distribution. If you have made
angeneral only the "taxable
Non4axable cavnurnts.
paid to you and
"after lax' empicyee contribution s to the Retirement System. these contributione wm be non-taxable when they are
contributions you made from your own pay that were
they cannot be reited over. (Atter4ax employee contributions generaty are
already taxed.)
2. DIRECT ROLLOVER distribution' es described
above, as long asIt
You can choose a direct rollover of sil cr any portion of your payment that is an "ehgible rollower
direct
equals $200 or more. In a the
rollover, dstribution
relover
eligible Ispaid from
drectly theretircritent system to an IRA cr another employer
it out of the IRA or the employer plan.
plan that accepts rdlovers. If you choose a direct rollowersyou are not taxed on a payment tintA you !ater taka
indudes
Otect RolbJer b an IRA. You can open an IRA to receive the drect rdlover. (The term "lRA", as used in this notice,
retirernent annuitles.) lf you choose tohave your payment made droctly to en
indvidual retirement accounts and inevidual RA,
drect rollowerto an IRA
contact an IRA sponsor (usually a thancial institution) to tind out how to have your payment made in a
to Invest your money, you can temporarily establish an LRAto receive the payment.
at that Institution. If you are unsure of hor
whether the 1RAyou choose will allow you to move all or a part of your
However, in choosing an IRA you may wish toconsider Retirement
paymers to another IRA at a later date without penames or other llrnitations- See IRS publication 590, Individual
Arrangements for more Information on IRA's (including simitson how citon you can roll over between IRA's).
Thacr Rarnwr If you are employed by a new employer that has a plan and you want a dired rdlover to that plan, ask the
id a Plan
accept your rollover. If your new employers plan does not accept a rollover, you can choose
administrator of that plan whether It wil
a direct Idlover to an IRA
3, PAYMENT PAID TO YOU
taxed in the year you receive it unless, within
If you have the payment made to you, it is subject to 20% income tax withholding. The payment 18
apply.
60 days, you rdl it over to an IRA or another plan that accepts rollovers. If you do not Idi t oveF,special taX fules may
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
EIsLRS Soanned Copy page 5 of 6
RS5914(Rev05/t1)Page3
MCOME TAX WITPlHOLDING:
or rnere, the Retirement Systemis
required
If any portlen c(the payment to you is an eligible rdlover Astsibution of $200
MandalbrvWithhokfino.
amountissent to the IRS as Income tax withholding. For exarnpte, if ycur engiblerenover dstribution
by law to withhdd 20% of that amount. This withhold $2,000 as income tax, However, when you prepare your
is $10,000, only $8,000 will be paid to you because the Retirement System must
theAsB$10,000asapaymenttom the Retirement System. You will report the $2,000 es tax withheld
Income tax retum for the year, you wig report
income you
tax
and It will be credited against any neefortheyear-
over all or part of It to an IRA or another
If you have an eligible rdIover distribution paid to you, you can still decide to Idl
Sktv"Da y RoBo stoction.
If
you
rollovers. deddetoroll you
over, rnust
make the within
rottower 60days ater you receive the payment. The siortion
that
employer plan accepts
IRA or the employer plan. You can rerl over up to 100% of the eliable
of your payment that Is rated over will not be taxed untli you take It out of the
choose to rot over 100%, you must find other money within the
rollowerdstribution Includng an amount equal to the 20% that was withheld. If you
to
period to
contributethetRA ortheother the 20% that was withlield. On the other hand, if you rol)over only the
employer plan toreplace
60-day
8084 that you received, you wig be taxed on the 20% that was withheld,
you. You win receive $8,000 and $2,000
Example: Your eligible rollover distribution is 610,000 and you chocee to have it paid to
you may roli over the entire $10,000 to an
wII be sent to the IRS as income withholding. Within 80 days efter receMng the $8.000, $2,000
Retirement System andyou will have totind
IRA or employer plan. To do this you Id1 over the $8,000 you received from the
is not taxed until you take It out of the IRA or employer
tom other sources (your savings, a loan, etc.). In this case the antire $10-000
you may get a refund of the $2,000 withheld.
plan. If you roA over the entire $10,000, when you file your Income tax retum
your
you did not rollover s taxed in the year It was withheld. When you file
If, on the other hand, you roll over the $8,000, the $2,000 refundis to be larger if you rdi over the
get
Income tax retum you maya refund
ofpartof
the $2,000
withhold.
(However,
any likely
entire $10,000).
in addition to the
if you receive a payment before the age of 55 and you do not mt 11over, then,
portion of the payment. The additionst 10% tax does not apply
regular Incornelax, you may have to pay an extra tax 'equelto 10% of the taxable
service with your employer during or after the year you reach age 55, (2) used
to your paymentif it is (1) paid to you because you separate torn
on the edditional 10% tax.
to pay certain medical expenses. See IRS Form 5329 for more inferination
qualifies as a
the year you seceive it. However,ifit
If your eligible rdlover distribution is not rdled over, t wtil be taxed in
SpgcieI Tex neatment
be for
ellgble speclel
tax A
treatment-lumpsum dstribution is a payment, within one year, of your entire balance
%mp sum distributler
, 11may
service with your employer, For a payment to qually as a
separated tom
with the Retirement System that is payable to you because you have
you
detribution, musthave beena In
participant
theRetirement System for at teast Aveyears. The special tax treatrnent for lump sum
lump sum
is described below.
dstributons
and you were bom before
ff you receive a tump sum distributton averaging"
If you were bom bef bre January 1, 1936.
Ten Year Averaabct.
elecdon
to the
figure taxonthepaymentDy "10-year
using (using 1986
January 1, 1936, you can make a one-time
tax rates), The 10-year averaging rules often reduces the tax you ove,
CepMelGain neetment in addtlen, if you receive a tump sum astribution and you were
If you were bom betbre January 3, 1930,
you elect
tohave the of
part yourpaymentthat is attributable to your pre-1974 participation in
January 1, 1936,
bom tefore may
systems(if taxedas gain
capital
long-term atarate
of20% There are other limits on the spedal tax treatment
the satirement any) treatment only once in your ilfetime arid the election
distributions.
Forexample,youcan elect
generally thisspeclat
tax
for lump sum
sum that
distributions youreceive
Inthesame year.you
If have previously rdted over a payment trom the Retirement
applies to aGlump
the Retirement System.11you rdl over your payment to
Inter payments tom
System, you cannot use this special tax treatment for
you wilnotbeabletouse apecial
this taxtreatment
for payments from the IRA Also, if you rdl over only a perfon of
later
an IRA, restrictions are described
for the rest of the payment, Addtional
your payment to an IRA this special tax treatment is net available
detrtbutions and how you elect the special (ex treatment.
In IRS form 4972, which has mese Information on lump sum
HOW M OBRIN ADDm0NAL INFORMATION
conplex
that inight apply to your payment. The rules described above are
This notice summarizes only the Federal (not State or local) tax rules advisor
conditions
and that
exceptions arenot In
Included this Therefore. you may went to consult with a professional tax
notice.
and contain many can find more specific information on the tar treatment of
paymentqiyourwithdrawal
fromthe System.
Retirement you
Also,
before you take a Retirement
Pension and Annulty Income, and IRS Publication 590, Indvidual
payrnents from qualitled retirement plans in litS Publication 575, gov or by calling 1-800-TAX-FORMS-
your local IRS ofitoe. the 1RS'sIntemet Website at www.Irs
Arrangements. These publications are available tom
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022
r-mas, scanned copy page 6 of 6
AS5014(RevOM1) Page4
Te Be Complet9dBy Employer employment
your last public
and have terminated
mlthin
be completed
This section gust by other than a State agency,
If yoti were employed
the last twelve months.
and is not on any authorized feeve of abserice.
employment on
I certify that the member was separated from
appear onthepayroll report for the month of
The members name last appeared, or will
Retirement System on cr about
This report was, cr will be, sent to the
were as foBoss:
. and the retirement contributlans, if any,
Gross eamings for the 11nalmonth were $
Loan S
Arrears 3
Normal (or COESC) S
( )
Date Number
Telephone
Signature Utle
Authorteed
funds.
your taxÄfeferred
transfer
be completed
The next section must 15you want the Retirement System to
DIRECT TRUSTEE.TO-TRUSTEE TRANSFER
MEMBER IDEN11FICATION
ComptroBerof the State of New Yortsas
hereby request that the
I I have appled for to my accetmt
distribution
non-periodc
Systems transfer the taxable partlen of the
trustee of the New York State and Local Retirement plan
refframent
talifiert
inr my IRA cr rther en
. the instne
with
Number'
Social Security
Date
Signature
TRUSTEE1NFORMATION
sent to us.
request the transfer proceeds as noted above to be
Ims established an account with us and we
The account number for this indMdualis
Please make the check payable to:
Tnistemfor the IRA
as
Custodian Qualified Plan
r(
Date
Signature
Trustee/Centedlan
Trustee/Custoden Address:
Telephone Number ( )
Systems
to: New York State and Local Retirement
Return thts entire doctanent WithdrawalsUnit - Mall Drop 5-8
110 State 8treet
Albany, New York 12244
of this form will be processed.
Only the original
signatures
original are not nepentable.
which
Coples cr facsimiles do not cordain
PERSONAL PRIVACY PROTECTzN LAW the RetirementSystemisrequiredtomainlein
ursuanttothe Retirementand SocialSecurityLaw,
advisedthat resultinthe falknetopsy bonests.TheSystern
wth the PersonetPrivacyLaw ouorehereby
Irrnecordance toprovideinforyneton
bonetts.Failure
selcuate may NewYorkStateand
e eggibRyforaridto
records.Therecordsorenecessaryto date thesereconiclethe Directorof MemberServkes,
provide birormationroparticipatingemployers.ThealAclefresponatileIbrmaintaining
contain or
905-0990 (5t 474-7736
Inthe N
Albany, ores.
ewYork
may In
Albany,NY 12244;TelephoneNumber(886)
LocalRelIrementSystm
*SOctAL SECURITY DISCLQ SURE REQUIRElulENT AccountNumberis mendstorypureusntto Sections
11,34,
advisedthat declosureof theSocialSecurity System.
the edmiristrationofthe Retirernent
wth the FederalPdvecyActof 1974,you erehereby
In occordance r
ecordsendin
retitement
inidentiffing
numberwit beused
St end334ofthe Rathementand SodalSecurityLaw.The
Preview
FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 "6" EXHIBIT FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 usLas snar==a copy page 1 or 6 OfficeoftheNewYorkStatoComptroller ThomasP.OINapoli New YorkstateendLocafRetirementSystem Employees'RetirementSystem PoliceandFireRetirementSystem 12244-000' 110Statestreet,Albany,NewYork Phone:1-866-80049900-618-474-7736 Far518-402-4433 E-mail:nyslrsinfo@osc.stateny,us Web;wnwoac.state.nyus/ralira December 27, 2013 Marianne F Kelly In reply refer to 41 Easy St Reg. No.: 50667500 Hurley NY 12443 Dear Member: Our records indicate that you are no longer working for a public employer that participates in this Retirement System. Since you are not eligible for a retirement your- in this Retirement System will benefit, membership terminate for inactivity on October 31, 2019, unless you return to public employment with a participating employer before then. Public employment is paid service with New York State, a county, city, town, villa ge, school district or public authority. I f you are currently in public employment, please contact us immediately. If your employment is covered by this Retirement System, we must update your status . If you are now a memner or another New York State Retirement system, you may be eligible to transfer your membership and service credit from this system to your current system. (When you contact us, we will provide you with additional information and forms if this applies to you. You currently have $7.97 on deposit with us. You may withdraw these funds at any time, by completing the enclosed Withdrawal Application and returning it directly to us at the above address . It will not be necessary for you to have the employer certification completed. If yo·u have an outstanding loan balance when we process your Withdrawal Application, we will deduct the amount of your loan, unpaid interest, loan insurance premiums and federal taxes, if applicable. If you do not withdraw, your funds will remain on deposit and continue to earn interest until your membership teminates, as mandated by law. Please notify us of any change in your mailing address to ensure you receive your annual member statements and other important correspondence. If you return to public employment before your membership terminates, you will resume earning credit toward your retirement. S- v20 FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 YSLRs S==M Copy page 2 of 6 Once our membership terminates, interest will no longer accrue on your contr ution balance or on any outstanding loan balance, and your contribut ions will be reduced by any remnaining loan balance. Any loan balance amount not previously taxed will be reported to the Internal Revenue Service in the year your membership terminates, and may be subject to federal tax withholding. Whether your membership terminates due to inactivity or through your voluntary withdrawal, if you later re-enter public employment, and become a member of a public Retirement System in New York State, you may apply for a reinstatement to your previous tier and date of membership. I f you have any questions, you may contact us toll -free at 1-866-805-0990 (or 518-474-7736 in the Albany, New York area), or write to us at the above address. Sincerely , John Wheeler Employees' Retirement System Examiner V Member & Employer Services JW/ABC966 MAB18 Enc. FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 Mshits sma-1 copy page 3 of a Office of the New York State Compt-oller Thomas P, DINapoll "7mY k.Sat d oc ant Snt" Withdrawal Application Polloe and Fire Retirement System PIO State Street Albany, New York12244-0001 Phone: 1-866-805-0990 or St 8-474-7736 Fax: 516-402-4433 heb· E-mail: nyslrsinfo@osc,state.ny.us www.osc.state.ny.ustretire RS 6014L-6 (Rev 05/11) This form Is for terminating your membership In the New York State and Local Retirement Systems. Please read the following: You do not become eligible for retum of your contributtons (if any) until 15 days after separation ftom service. If you have not made any contributions, there will be no payment due you. Membership may be terminated, but not before 30 days ofter separation tom sendee Any toan balance which codstsat the time of terrnination will be deducted itom your refund. Ter 1, 2, 3 & 4 membere with five years of created service how vested rits. Tier 3 and 4 members with more than five but fewer than ten years of cred1ed service rnay terminate membership and forfeit their vested dghts. Nor 5 members do nol have vested rights until they attain ten or more years oIservice. Generally, membershp cannd be terminated If a member has vested rights and ten or more years of credited sendce. Ifyouhave joined andher retirement system operated by the State of New York or a paltical subdivision, you may be able to transfer your membership to that system. Tb do so, do not complete this form but send for form RS 5223, Request to Transfer Membership, By transferring your entire membership to another retirement system your contributions retain their tax-deferred status. If you do not transfer when the prMlege la avalfable, you may not be able to get credit for this service d a later date. This section to be completed by Member - Cornplete (print or type) Items 1 - 6 below You Instructions MUST SION the declaration, in nk. You MUS_ _choosea payment option on the lower half of this form. To the Comptroller of the 8tate of New York: I request that my membership In the retirement system be terminated and I apply for the retum of cenbibutions and nterest credited on my account4 in conskieraUon d the terrnination of my membrship I hereby waive for myself, my heira and assigns all any my right, title, aMInterest in the funds of any and all benefits flowing from merrtership In the retirement system. I have terminated my employment and I am not now employed in position any ingovemment service in which Inembership in this retirement system is avaltable. O I am a ¶er 1, 2, 3.or 4 member credited with at least 1ve years of service and understanc|that I am eligible for a future benefit. As a vested Tier 1, 2, 3 or 4 member, I could receive an estimate of my tuture benefits. By diecleng this box I am choosing to waive such estimate and that my application be processed irnmediately. 1. Name Phrase pmvkfe e telephone number where you can be reached during the day. This ww only be used H mere ore quesflons which 2. Social Security Number" may delay the processing of your applic.ation. 3. t.ast Public Employer (Area Code)TesephoneNumber 4. Last Day Worked, if Known 5. Registration Number 6. Date of Birth Monm Day Year 7. Your home address· - Sheet Chy Siste Zip Code 8. Payment Election Please indicate your choice donly one of the fdlesing payment options: I have read the information regardag federal tax withhdding and rolfovers d the distrhution payaNe to me. I elect to receive the entire distrbution rather than reling over ell or part of the taxable portion of such distrbution to a quallted plan or IndMdual retirement account. I understand that Federal law requires that twenty percent of the taxable portim d such distribution wiNbe wthheld fcr laxes pursuant to the Internal Revenue Code and epplicable regulations. I further understand that under applicable law and regulations, I have the sight to review this notice for 30 days priorto making this election, and hereby waive such right O Ihave read the Inforrnation regardng federal tax withholding and rat overs of the astribution payable to me. I eled to receive the entire distrbution rather than rcilog over all or part of the taxable portlan of such distribution to a quallAedplan or individual retirement account. I understand that Federal law requires that twenty percen1of the taxable portion of such distributlan wltl be wthhold Item the payment, pwsuant to the Internal Revenue Code and applicable regulations. I further understandthat I have the rl t to review thle notice for 30 days prior to the processing of my reftmdand that during that period no pay ment will be made. O I have read the Information regardng federal tax withholdng and reliaters of the dshibution payable to me. I elect to rollover the taxabkr portion of such distribution to a qualllied plan or individual retirernent account as indicated on the Trustee-to-Trustee section d this application. Signature Date Please go toback of thisform formore information FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 rYSLRS Saanned Copy page 4 of d RS6014(Rev05h1) Page2 SPECIAL TAX NOTICE REGARDING REEREMENT SYSWM WITHDRAWALS This notice contains Important information you wtil need before you decide how to receive your wthdrawal payment from the New York State and Local Retirement Systems. SUMMARY Awithdrawalpayment from the Retirement System consists of a taxable amount, and may also include a non-taxable amount. The taxable amount eligible for "rollover" can be taken In one of two ways. You may have at cr any portion of your taxable payment either 1) PAID LNA 'DIRECT ROLLOVER'or your Individual retirement arrangement (IRA) or to 2) PAID TO YOU. A rolloweris a payment of the taxabte portion of your Retirement System withdrawal to another employer plan. This choice will affect the tex you owe. If you choose a DIRECT ROLLOVER: a Your rehmd wit not be taxed in the curent be withheld. year and no Income tax w) a Your refund will be made directly to your IRA or, :fyou choose, to another employer plan that accepts your rdlover. a Your refund wm be taxed Inter when you take It cut of the IRA or the employer plan. If you choose to have your Retirement System withdrawal PAID TO YOU: - 20% of the taxable You will receive only 60% of the taxable portion of the refund because the Retirement System Is required to wthhdd portion of the refund and send t to the IRS as Income tax withholding to be credited against your taxes. * Your payment wit be taxed h the current year unless you roll it over. You may be able to use special tax rules that could reduce the tax 10% tax. you owe. However, If you receive the refund before age 55, you also may have to pay an addtlenal The a You can roll over the payment to your IRA or to another employer plan that accepts your reitcver within 60 days of receiving the payment. amount rolled o/or will not be taxed until you take t cut of the IRA or the other employer plan. a If you went toroll over 100% ofthe payment toan employer plan, you must lind other money to replace the 20% that was withheld. IRA or andhar If you roll over only the 80% that you received, you will be taxed on the 20% that was withheld and is not rdled over. MORE INFORWIAMON 1, PAYMENTSTHAT CAN AND CANNOT BE ROLLIEDOVER dstributions." This means that Payments trom the Retirement System may be "eligible rdlover they can be rolled over to an IRA or to another employer plan that accepts rollovers. The Retirement System will tag you what portion of your payment is an eligible rollowerdistifoution, The followhg types of payments cannot be refled over: portion" of your payment is an elldble rollover distribution. If you have made angeneral only the "taxable Non4axable cavnurnts. paid to you and "after lax' empicyee contribution s to the Retirement System. these contributione wm be non-taxable when they are contributions you made from your own pay that were they cannot be reited over. (Atter4ax employee contributions generaty are already taxed.) 2. DIRECT ROLLOVER distribution' es described above, as long asIt You can choose a direct rollover of sil cr any portion of your payment that is an "ehgible rollower direct equals $200 or more. In a the rollover, dstribution relover eligible Ispaid from drectly theretircritent system to an IRA cr another employer it out of the IRA or the employer plan. plan that accepts rdlovers. If you choose a direct rollowersyou are not taxed on a payment tintA you !ater taka indudes Otect RolbJer b an IRA. You can open an IRA to receive the drect rdlover. (The term "lRA", as used in this notice, retirernent annuitles.) lf you choose tohave your payment made droctly to en indvidual retirement accounts and inevidual RA, drect rollowerto an IRA contact an IRA sponsor (usually a thancial institution) to tind out how to have your payment made in a to Invest your money, you can temporarily establish an LRAto receive the payment. at that Institution. If you are unsure of hor whether the 1RAyou choose will allow you to move all or a part of your However, in choosing an IRA you may wish toconsider Retirement paymers to another IRA at a later date without penames or other llrnitations- See IRS publication 590, Individual Arrangements for more Information on IRA's (including simitson how citon you can roll over between IRA's). Thacr Rarnwr If you are employed by a new employer that has a plan and you want a dired rdlover to that plan, ask the id a Plan accept your rollover. If your new employers plan does not accept a rollover, you can choose administrator of that plan whether It wil a direct Idlover to an IRA 3, PAYMENT PAID TO YOU taxed in the year you receive it unless, within If you have the payment made to you, it is subject to 20% income tax withholding. The payment 18 apply. 60 days, you rdl it over to an IRA or another plan that accepts rollovers. If you do not Idi t oveF,special taX fules may FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 EIsLRS Soanned Copy page 5 of 6 RS5914(Rev05/t1)Page3 MCOME TAX WITPlHOLDING: or rnere, the Retirement Systemis required If any portlen c(the payment to you is an eligible rdlover Astsibution of $200 MandalbrvWithhokfino. amountissent to the IRS as Income tax withholding. For exarnpte, if ycur engiblerenover dstribution by law to withhdd 20% of that amount. This withhold $2,000 as income tax, However, when you prepare your is $10,000, only $8,000 will be paid to you because the Retirement System must theAsB$10,000asapaymenttom the Retirement System. You will report the $2,000 es tax withheld Income tax retum for the year, you wig report income you tax and It will be credited against any neefortheyear- over all or part of It to an IRA or another If you have an eligible rdIover distribution paid to you, you can still decide to Idl Sktv"Da y RoBo stoction. If you rollovers. deddetoroll you over, rnust make the within rottower 60days ater you receive the payment. The siortion that employer plan accepts IRA or the employer plan. You can rerl over up to 100% of the eliable of your payment that Is rated over will not be taxed untli you take It out of the choose to rot over 100%, you must find other money within the rollowerdstribution Includng an amount equal to the 20% that was withheld. If you to period to contributethetRA ortheother the 20% that was withlield. On the other hand, if you rol)over only the employer plan toreplace 60-day 8084 that you received, you wig be taxed on the 20% that was withheld, you. You win receive $8,000 and $2,000 Example: Your eligible rollover distribution is 610,000 and you chocee to have it paid to you may roli over the entire $10,000 to an wII be sent to the IRS as income withholding. Within 80 days efter receMng the $8.000, $2,000 Retirement System andyou will have totind IRA or employer plan. To do this you Id1 over the $8,000 you received from the is not taxed until you take It out of the IRA or employer tom other sources (your savings, a loan, etc.). In this case the antire $10-000 you may get a refund of the $2,000 withheld. plan. If you roA over the entire $10,000, when you file your Income tax retum your you did not rollover s taxed in the year It was withheld. When you file If, on the other hand, you roll over the $8,000, the $2,000 refundis to be larger if you rdi over the get Income tax retum you maya refund ofpartof the $2,000 withhold. (However, any likely entire $10,000). in addition to the if you receive a payment before the age of 55 and you do not mt 11over, then, portion of the payment. The additionst 10% tax does not apply regular Incornelax, you may have to pay an extra tax 'equelto 10% of the taxable service with your employer during or after the year you reach age 55, (2) used to your paymentif it is (1) paid to you because you separate torn on the edditional 10% tax. to pay certain medical expenses. See IRS Form 5329 for more inferination qualifies as a the year you seceive it. However,ifit If your eligible rdlover distribution is not rdled over, t wtil be taxed in SpgcieI Tex neatment be for ellgble speclel tax A treatment-lumpsum dstribution is a payment, within one year, of your entire balance %mp sum distributler , 11may service with your employer, For a payment to qually as a separated tom with the Retirement System that is payable to you because you have you detribution, musthave beena In participant theRetirement System for at teast Aveyears. The special tax treatrnent for lump sum lump sum is described below. dstributons and you were bom before ff you receive a tump sum distributton averaging" If you were bom bef bre January 1, 1936. Ten Year Averaabct. elecdon to the figure taxonthepaymentDy "10-year using (using 1986 January 1, 1936, you can make a one-time tax rates), The 10-year averaging rules often reduces the tax you ove, CepMelGain neetment in addtlen, if you receive a tump sum astribution and you were If you were bom betbre January 3, 1930, you elect tohave the of part yourpaymentthat is attributable to your pre-1974 participation in January 1, 1936, bom tefore may systems(if taxedas gain capital long-term atarate of20% There are other limits on the spedal tax treatment the satirement any) treatment only once in your ilfetime arid the election distributions. Forexample,youcan elect generally thisspeclat tax for lump sum sum that distributions youreceive Inthesame year.you If have previously rdted over a payment trom the Retirement applies to aGlump the Retirement System.11you rdl over your payment to Inter payments tom System, you cannot use this special tax treatment for you wilnotbeabletouse apecial this taxtreatment for payments from the IRA Also, if you rdl over only a perfon of later an IRA, restrictions are described for the rest of the payment, Addtional your payment to an IRA this special tax treatment is net available detrtbutions and how you elect the special (ex treatment. In IRS form 4972, which has mese Information on lump sum HOW M OBRIN ADDm0NAL INFORMATION conplex that inight apply to your payment. The rules described above are This notice summarizes only the Federal (not State or local) tax rules advisor conditions and that exceptions arenot In Included this Therefore. you may went to consult with a professional tax notice. and contain many can find more specific information on the tar treatment of paymentqiyourwithdrawal fromthe System. Retirement you Also, before you take a Retirement Pension and Annulty Income, and IRS Publication 590, Indvidual payrnents from qualitled retirement plans in litS Publication 575, gov or by calling 1-800-TAX-FORMS- your local IRS ofitoe. the 1RS'sIntemet Website at www.Irs Arrangements. These publications are available tom FILED: ALBANY COUNTY CLERK 04/18/2022 03:52 PM INDEX NO. 902932-22 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 04/18/2022 r-mas, scanned copy page 6 of 6 AS5014(RevOM1) Page4 Te Be Complet9dBy Employer employment your last public and have terminated mlthin be completed This section gust by other than a State agency, If yoti were employed the last twelve months. and is not on any authorized feeve of abserice. employment on I certify that the member was separated from appear onthepayroll report for the month of The members name last appeared, or will Retirement System on cr about This report was, cr will be, sent to the were as foBoss: . and the retirement contributlans, if any, Gross eamings for the 11nalmonth were $ Loan S Arrears 3 Normal (or COESC) S ( ) Date Number Telephone Signature Utle Authorteed funds. your taxÄfeferred transfer be completed The next section must 15you want the Retirement System to DIRECT TRUSTEE.TO-TRUSTEE TRANSFER MEMBER IDEN11FICATION ComptroBerof the State of New Yortsas hereby request that the I I have appled for to my accetmt distribution non-periodc Systems transfer the taxable partlen of the trustee of the New York State and Local Retirement plan refframent talifiert inr my IRA cr rther en . the instne with Number' Social Security Date Signature TRUSTEE1NFORMATION sent to us. request the transfer proceeds as noted above to be Ims established an account with us and we The account number for this indMdualis Please make the check payable to: Tnistemfor the IRA as Custodian Qualified Plan r( Date Signature Trustee/Centedlan Trustee/Custoden Address: Telephone Number ( ) Systems to: New York State and Local Retirement Return thts entire doctanent WithdrawalsUnit - Mall Drop 5-8 110 State 8treet Albany, New York 12244 of this form will be processed. Only the original signatures original are not nepentable. which Coples cr facsimiles do not cordain PERSONAL PRIVACY PROTECTzN LAW the RetirementSystemisrequiredtomainlein ursuanttothe Retirementand SocialSecurityLaw, advisedthat resultinthe falknetopsy bonests.TheSystern wth the PersonetPrivacyLaw ouorehereby Irrnecordance toprovideinforyneton bonetts.Failure selcuate may NewYorkStateand e eggibRyforaridto records.Therecordsorenecessaryto date thesereconiclethe Directorof MemberServkes, provide birormationroparticipatingemployers.ThealAclefresponatileIbrmaintaining contain or 905-0990 (5t 474-7736 Inthe N Albany, ores. ewYork may In Albany,NY 12244;TelephoneNumber(886) LocalRelIrementSystm *SOctAL SECURITY DISCLQ SURE REQUIRElulENT AccountNumberis mendstorypureusntto Sections 11,34, advisedthat declosureof theSocialSecurity System. the edmiristrationofthe Retirernent wth the FederalPdvecyActof 1974,you erehereby In occordance r ecordsendin retitement inidentiffing numberwit beused St end334ofthe Rathementand SodalSecurityLaw.The