STATE UNIVERSITY OF NEW YORK OPTIONAL RETIREMENT PROGRAM

EMPLOYEES� RETIREMENT SYSTEM DETERMINATION


Name: __________________________________


Social Security #: _________________________


I am presently a member of the New York State Employees' Retirement System and have elected the Optional Retirement Program.

I understand that on the effective date of such election I shall become a person who shall be deemed to have discontinued service for the purpose of determining eligibility for rights and benefits in the Employees� Retirement System.  I further understand that if I do not withdraw my accumulated contributions (an option available to me only if I have fewer than 10 years of service in ERS), my continued services with State University under the Optional Retirement Program will be deemed member service in the Employees� Retirement System for the purpose of determining eligibility for any vested retirement allowance, retirement allowance or ordinary death benefit dependent upon a specific period of total service or upon attainment of a specified age while in service or upon death while in service but that the amount of any benefit payable as a result of such eligibility will be based only on service otherwise creditable to me in such system and my compensation during such service.

I further understand that I may withdraw my accumulated contributions from the Employees� Retirement System, and that in so doing I will cease to be a member of such system, and will not be eligible for any benefits from such system.

In consideration of this, I desire to:

		Leave my accumulated contributions in the retirement system.


		Withdraw my accumulated contributions from the retirement system terminating membership, and submit here with 		the appropriate form for withdrawal of such contributions. 




Signed: _______________________________		Date: ____________________________