Form F233 - Agency-To-Agency Transfer Notification printable pdf download

Form F233 - Agency-To-Agency Transfer Notification

F233

NYCERS USE ONLY

*233*

Mail completed form to:

30-30 47th Avenue, 10th Fl

Long Island City, NY 11101

Agency-to-Agency Transfer Notification

This form is to be completed by any agency to notify NYCERS when a new employee who is ALREADY a NYCERS member has

transferred from: (1) Any New York City agency; (2) New York City Transit or MTA Bridges and Tunnels; (3) any facility of the New

York City Health and Hospitals Corporation; or (4) any campus of the City University of New York. This will ensure that the

appropriate pension payroll deductions continue to be deducted from your employee’s paycheck. Thank you for helping us keep our

member records accurate by submitting this information to NYCERS.

THIS FORM MUST BE COMPLETED BY THE AGENCY ONLY

EMPLOYEE INFORMATION

NYCERS Member Number

Last 4 Digits of SSN

Employee ID

Current Salary

First Name

M.I.

Last Name

Address

Apt. Number

City

State

Zip Code

AGENCY INFORMATION

CURRENT Agency

Agency Bank Number

Date of Appointment

Title

Title Code

[MM/DD/YYYY]

Personnel/Benefits Representative

Phone Number

E-mail Address

(

)

Employee's FORMER Agency

Signature of Personnel/Benefits Representative

Date

R02/17

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Form F233 - Agency-To-Agency Transfer Notification