Form F399 - Affidavit Concerning Lost Check
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4NYCERS USE ONLY
F399
*399*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Affidavit Concerning Lost Check
This form is for members and pensioners who wish to report the loss of a check. In order to report such a loss, you must fill out this
form and return it to NYCERS. Please be sure to read the instructions below and complete the requested information. NOTE: If the
address you provide on this form is different from your address in our system, the new address will become your official
address in our records. If you have any questions regarding this form, please contact our Call Center at 347-643-3000.
Member Number
OR
Last 4 Digits of SSN
Home Phone Number
Work Phone Number
Pension Number
(
)
(
)
First Name
M.I.
Last Name
Address
Apt. Number
State
Zip Code
City
TYPE OF CHECK LOST (please check only one box from Section A or Section B):
Section A
Tier 1 or Tier 2 Loan
Monthly Pension Payment
Fractional Benefit
A replacement (paper check) will be sent to the mailing address on file if you checked a box in Section A. If you would like your
Monthly Pension Payment direct-deposited in the future, you must complete and submit Form 380, available at
--OR--
Section B
Tier 3, Tier 4 or Tier 6 Loan
Lump-Sum Survivor Benefit (Death in Service)
Refund (all tiers)
Lump-Sum Pensioner Survivor Benefit
If you checked a box in Section B, your replacement check can be direct-deposited into your bank account. Please see pages 3 and 4
for instructions. NOTE: Lost rollover checks CAN ONLY BE REPLACED BY A PAPER CHECK, not by direct deposit.
STATEMENT:
Although I have been informed by NYCERS that the type of check designated above in the amount of
[MM/DD/YYYY]
$
was issued to me and mailed to the following:
and dated
/
/
Address
Apt. Number
State
Zip Code
City
I hereby inform NYCERS that I have not received the above-mentioned check. I further state that I do not know where this check may
be at the present time, and that I am filing this form to have a replacement check issued to me in the same amount as the original check
issued by NYCERS. If other circumstances exist, please state briefly: (Example: Check was received but stolen or lost after receipt)
In the event that the original missing check comes into my possession at any time, I promise to return it immediately to NYCERS at the
above address. If at any time it is found that the original check has been cashed by me, I hereby authorize NYCERS to deduct the
amount of the check from any future payments.
Sign this form and have it notarized, Page 2
R11/17
Page 1 of 4
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