New York State and Local Retirement System

Disability Retirement Benefits

If you are seriously ill or injured and it is doubtful whether you will be able to return to work, you should seriously consider filing a disability retirement application. If, during the processing of your application, your condition improves and you are able to return to work, you may withdraw your application at any time before it has been approved.

Applications must be received by the Retirement System to be considered filed and must be filed prior to the applicant’s death.

To file:

Applications for Disability Retirement

Applications can only be signed by the member, a person authorized with the member’s power of attorney or the employer. If the member is terminally ill, an option election form should be filed along with the disability retirement application.

Article 14 Disability Retirement Application

For Tier 3 Employees’ Retirement System members and Tier 3 Police and Fire Retirement System members covered by Article 14 benefits. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6411, Rev. 12/13)

Article 14-B Disability Retirement Application

For county sheriffs, undersheriffs and certain deputy sheriffs whose employers elected coverage under Sections 555, 556, 557 and 558 of the Retirement & Social Security Law (RSSL). This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6408, Rev. 12/13)

Article 15 Disability Retirement Application

For Tier 3, 4, 5 and 6 members. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6340, Rev. 12/13)

605-A Accidental Disability Retirement Application

For court officers and peace officers in the Unified Court System. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6410, Rev. 12/13)

Environmental Conservation & Regional State Park Police Disability Retirement Application

For State Environmental Conservation and Regional State Park police officers covered by Section 363-e (RSSL). This is a two page form and a HIPAA waiver, please submit all three pages.

(PF6091, Rev. 12/13)

507-A Disability Retirement Application

For Tier 3, 5 and 6 NYS correction officers and security hospital treatment assistants. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6409, Rev. 12/13)

Ordinary Disability Retirement Application

For PFRS members and Tier 1 and 2 ERS members. This application is not for Tier 3 members covered under Article 14. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6038, Rev. 12/13)

Performance of Duty Disability Retirement Application

For NYS correction officers and security hospital treatment assistants who are covered by Chapters 653 and 722 (RSSL). This application is not for Tier 3 PFRS members covered under Article 14. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047-A, Rev. 12/13)

Performance of Duty Disability Retirement Application

For sheriffs, deputy sheriffs, undersheriffs and county correction officers in counties that elected Sections 63-B, 63-C, 607C and 607D. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047-B, Rev. 12/13)

Accidental Disability Retirement Application

For Police & Fire Retirement System members and Tier 1 and Tier 2 Employees’ Retirement System members. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047, Rev. 12/13)

Performance of Duty Disability Retirement Application

Application for Police & Fire Retirement for Disability Incurred in Performance of Duty. This application is not for Tier 3 PFRS members covered under Article 14. This is a two page form and a HIPAA waiver, please submit all three pages.

(PF6047, Rev. 12/13)

State Police Disability Retirement Application

For Tier 1, 2, 5 and 6 members and officers employed by the Division of NYS Police. This is a two page form and a HIPAA waiver, please submit all three pages.

(PF6090, Rev. 12/13)

World Trade Center Accidental Presumption Application

Application for those involved in the rescue, recovery or clean up operations of the World Trade Center aftermath. This is a two page form and a HIPAA waiver, please submit all three pages.

(RS6047-W, Rev. 3/15)

Application for Conversion of Service or Disability Retirement to Accidental Death Benefit for Victims of the 2001 World Trade Center Disaster

For beneficiaries of World Trade Center disaster victims. A beneficiary must file this application to convert a deceased retiree’s pension benefit to an accidental death benefit.

(RS6418-W, Rev. 3/15)

Authorization for Release of Health Information Pursuant to HIPAA

HIPAA forms must be submitted with all disability applications.

(RS6429, Rev. 5/15)

Option Election Forms

Option election forms must be signed by the member; or if the member is incompetent, the member’s spouse; or a person authorized with the member’s power of attorney. The employer cannot sign the option election form.

Retirement Option Election Form for Tier 3, 4, 5 and 6 ERS members (RS6399, Rev. 4/13)

Retirement Option Election Form for Tier 1 members (RS6109-A, Rev. 12/04)

Retirement Option Election Form for Tier 2 members (RS6163-A, Rev. 12/04)

Power of Attorney

Public Retirement System Special Power of Attorney Form This form is limited to retirement benefit transactions and does not apply to any other matters. (Rev. 11/10)