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Retirement Option Election Form with Partial Lump Sum Payment For Tier 2, 3, 5 and 6 Members — RS 6421-A (Rev. 8/14)
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Document Date: 2014-12-02 14:31:23

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File Size: 567,33 KB

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City

Albany / /

Company

State Street / /

Currency

USD / Rs / /

Organization

Direct Trustee-to-Trustee Transfer office of the New York State / Members Office / Local Retirement System Employees’ Retirement System Police / Call Center / New York State Comptroller New York State and Local Retirement System Employees’ Retirement System Police / Internal Revenue Service / Retirement System Police / /

Person

Mary Smith / John Smith / /

/

Position

Signature Date TRUSTEE / tax advisor / professional tax advisor / Director of Member and Employer Services / Governor / trustee / General / GENERAL INFORMATION ABOUT ROLLOVERS How / COMPTROLLER / administrator / /

ProvinceOrState

New York / New / /

URL

www.osc / www.irs.gov / /

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