Withdrawal Of Application For Service Retirement Rs 6354
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1Withdrawal of Application
RECEIVED
for Service Retirement
Office of the New York State Comptroller
New York State and Local Retirement System
RS 6354
Employees’ Retirement System
Police and Fire Retirement System
(Rev. 8/11)
110 State Street, Albany, New York 12244-0001
NOTE: If you withdraw your application for service retirement and later decide to retire, it will be necessary to file a
new application. The new application must be on file in the Retirement System at least 15 days, but not more than 90
days, before it can become effective.
1. Name (First, Middle Initial, Last)
2. Address
.....................................................................................
3. Social Security Number
.....................................................................................
.....................................................................................
4. Registration Number
5. Effective Retirement Date
Month
Day
Year
I request that my application for service retirement be withdrawn.
I understand that this request must be received in the Retirement System prior to my effective date of retirement
and that no request to withdraw my service retirement application can be honored after that date.
Signature
_______________________________________
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