Receipt Date. You must answer all questions in ink and the application must be signed and notarized, or it will be rejected.

Transcription

1 Office of the New York State Comptroller New York State ad Local Retiremet System Mail completed form to: NEW YORK STATE AND LOCAL RETIREMENT SYSTEM 110 STATE STREET - MAIL DROP 5-9 ALBANY NY Receipt Date Tiers 1 & 2 Loa Applicatio RS 5025 (Rev. 9/17) Please see pages 4 ad 5 for istructios o completig this form. If you are ot sure you are eligible for a loa, please call us toll-free at (866) or (518) i the Albay, New York area. You must aswer all questios i ik ad the applicatio must be siged ad otarized, or it will be rejected. 1 Persoal Iformatio A. Social Security Number Registratio Number (if kow) - - Employees Retiremet System (ERS) Police ad Fire Retiremet System (PFRS) Last Name First Name M.I. Permaet Mailig Address Street Address (Street or PO Box) Uit or Apt # Street Address City State Zip Code Home Phoe Work/Cell Phoe Extesio ( ) - ( ) Required Iformatio Must be Completed (See page 4 for istructios) If you participate i aother retiremet pla offered through your employer (such as a 457 deferred compesatio pla, 403-a qualified auity pla, 403-b tax sheltered auity pla or 401 qualified trust), ad have a existig loa through that pla, you must disclose this iformatio or this loa applicatio will be rejected. If you have memberships i both PFRS ad ERS, ad have a existig loa i oe System at the time you apply for a loa i the secod, you do ot have to iclude this iformatio below. The balaces required will be icluded automatically whe you apply for your loa. The Iteral Reveue Code requires us to cosider these loa balaces whe we calculate the taxability of a loa from our System. Note that this may result i sigificat tax cosequeces o your loa from this System. (See tax iformatio o page 5.) A. Do you have a outstadig loa balace with your curret employer through ay of the retiremet plas oted above? No Go to 3 Yes You must aswer the followig (If you have loa balaces outstadig with more tha oe employer retiremet pla, please provide the combied total of these balaces i each sectio below): B. How much moey do you curretly have ivested i the retiremet pla(s) from which your loa(s) was issued? C. What is your curret total balace outstadig o your pla loa(s)? D. I the past 12 moths, what was your highest loa balace through this pla(s)?

2 RS 5025 (Rev. 9/17) Page 2 of 5 See pages 4 ad 5 for importat iformatio ad istructios. Before choosig a loa type, call our automated iformatio phoe lie toll-free at (866) or (518) i the Albay, New York area. Oce you access the loa meu, you ca receive specific iformatio relatig to your accout for multiple ad refiaced loas. 3 Loa Type You must select ONLY ONE of the followig or we caot accept your applicatio. A. Loa Type 1 Check here if you wat a loa ad do NOT have a existig loa with us. B. Loa Type 2 (This is called a multiple loa.) Check here if you already have a loa with us ad wat to take aother loa. The sigle repaymet amout for multiple loas is higher tha a sigle repaymet o a refiaced loa. C. Loa Type 3 (This is called a refiaced loa.) Check here if you already have a loa with us ad wat to add to it. WARNING! The taxable amout for a refiaced loa will always be greater tha for a multiple loa, uless the etire amout of the refiaced loa is o-taxable. To avoid severe tax cosequeces, verify your taxable amout usig our automated iformatio lie. I am aware of the possible tax cosequeces of takig a refiaced loa ad authorize the Retiremet System to process my applicatio as idicated. 4 Loa Amout A. I am applyig for (Choose oly oe): i. A maximum NON-TAXABLE loa ii. A loa of: iii. A maximum loa B. Loa Repaymet Amout (per pay period) Higher Tha Miimum Miimum OR If you wat to pay higher tha the miimum required, ad choose Loa Type 2 (multiple loas), your payroll loa deductio will remai the same util all loas are paid or a ew loa is take. C. U.S. Citizeship Status (Choose oly oe): Citize* Residet Alie* No-Residet Alie** *If you are a U.S. Citize or Residet Alie: This form will be used as a substitute for the W-9 tax form. By completig ad sigig this form you are agreeig to the certificatio statemets outlied below. Uder pealty of perjury, I certify that: 1. The umber show o this form is my correct taxpayer idetificatio umber (or I am waitig for a umber to be issued to me); ad 2. I am ot subject to backup withholdig because: (a) I am exempt from backup withholdig or (b) I have ot bee otified by the Iter al Reveue Service (IRS) that I am subject to backup withholdig as a result of a failure to report all iterest or divideds, or (c) the IRS has otified me that I am o loger subject to backup withholdig (you must cross out item 2 if you have bee otified by the IRS you are curretly subject to backup withholdig because you failed to report all iterest or divideds o your tax retur), ad 3. I am a U.S. citize or other U.S. perso (defied i the istructios) ad 4. The FATCA code(s) etered o this form (if ay) idicatig that I am exempt from FATCA reportig is correct. (Note: This item does ot apply for the loa applicatio.) **If you are a No-Residet Alie: You must submit a W-8BEN tax form with your loa applicatio. Please refer to the istructios sectio for directios to obtai this form. Loa applicatios received without a W-8BEN tax form will be rejected. Federal Taxes must be withheld for No-Residet Alies (skip sectio 4D). D. Federal Tax Withheld If your loa is taxable, Federal law requires us to withhold 10 percet of the taxable amout of this loa, uless you check the box below (you may icur additioal taxes ad/or pealties if your withholdig is isufficiet). Federal withholdig ca sigificatly reduce the loa amout payable to you. Do ot deduct 10 percet withholdig tax. Note: If you are a U.S. Citize or Residet Alie livig outside of the Uited States, we are required to deduct 10 percet federal withholdig tax from your loa. Note: If you are a No-Residet Alie, we are required to deduct withholdig from your loa i accordace with the tax treaty betwee the Uited States ad your coutry. I may istaces, the amout withheld will exceed 10 percet ad will result i the issuace of a loa check i a amout cosiderably less tha the loa you are issued. 5 Payroll Iformatio A. Employer (Employer payroll from which loa repaymets will be deducted) B. Aual Salary C. Payroll Frequecy (Check oe box oly) Weekly Bi-Weekly Semi-Mothly Mothly Quarterly Semi-Aual Aual D. Employmet Term (Check oe box oly) I am a 12-Moth Employee I am a 10-Moth Employee I am a Seasoal Employee

3 RS 5025 (Rev. 9/17) Page 3 of 5 6 TO THE COMPTROLLER OF THE STATE OF NEW YORK: I am applyig for a loa from the Retiremet System as show above. I agree to deductios beig take from my salary for each future payroll period util the total amout due, icludig iterest, is repaid. I agree that my auity savigs accout be charged with the required loa isurace premiums util the loa is repaid. I agree that the rate of iterest o this loa shall be fixed by the Comptroller as provided for i the Retiremet ad Social Security Law. I certify that the iformatio o my applicatio is true ad complete to the best of my kowledge. I further certify that I am aware that ay false statemets I kowigly make or permit to be made o this or ay record of the retiremet system costitutes a crime puishable by potetial icarceratio ad other sactios. The Iteral Reveue Service does ot require your coset to ay provisio of this documet other tha the certificatios required to avoid backup withholdig. Sigature (must be siged i ik ad ackowledged by a otary) 7 ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLIC State of Couty of O the day of i the year before me, the udersiged, persoally appeared, persoally kow to me or proved to me o the basis of satisfactory evidece to be the idividual(s) whose ame(s) is (are) subscribed to the withi istrumet ad ackowledged to me that he/she/they executed the same i his/her/their capacity(ies), ad that by his/her/their sigature(s) o the istrumet, the idividual(s), or the perso upo behalf of which the idividual(s) acted, executed the istrumet. Notary Stamp NOTARY PUBLIC (Please sig ad affix stamp) PERSONAL PRIVACY PROTECTION LAW I accordace with the Persoal Privacy Law, you are hereby advised that pursuat to the Retiremet ad Social Security Law, the Retiremet System is required to maitai records. The records are ecessary to determie eligibility for ad to calculate beefits. Failure to provide iformatio may result i the failure to pay beefits. The System may provide certai iformatio to participatig employers. The official resposible for maitaiig these records is the Director of Member & Employer Services, New York State ad Local Retiremet System, 110 State Street, Albay, NY ; Telephoe Number (518) SOCIAL SECURITY DISCLOSURE REQUIREMENT I accordace with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the Social Security Accout Number is madatory pursuat to Sectios 11 ad 34 of the Retiremet ad Social Security Law. The umber will be used i idetifyig retiremet records ad i the admiistratio of the Retiremet System. BANKRUPTCY INFORMATION A loa from the Retiremet System based o a member s cotributios is ot a debt ad, therefore, is ot dischargeable i bakruptcy.

4 RS 5025 (Rev. 9/17) Page 4 of 5 Istructios ad Iformatio For Fillig Out Loa Applicatio 1 Persoal Iformatio Istructios A. Complete the etire sectio. 2 Required Iformatio Must be Completed Geeral Iformatio Your employer is a participatig employer i The New York State & Local Retiremet System (System). The System is a Sectio 401(a) qualified trust. I additio to membership i the System, your employer may offer other types of retiremet plas. Before we ca issue a loa to you, the Iteral Reveue Service requires us to iquire whether you have outstadig loas i other retiremet plas offered by your employer. For this purpose, iclude loas from plas sposored by the employer upo which your System membership is based. Loas from private sector employer plas or retiremet accouts are ot icluded. Two commo employer-sposored retiremet savigs plas are: Sectio 457, a deferred compesatio pla, is a volutary supplemetal retiremet savigs pla sposored by your curret employer. It eables public employees to save a portio of their gross pay before Federal ad State icome taxes are deducted. Sectio 403(b), a tax sheltered auity pla, is a employer-sposored retiremet savigs program. By law, participatio is limited to employees of public educatioal orgaizatios ad certai oprofit orgaizatios. Other, less commo employer-sposored retiremet savigs plas are: Sectio 403(a) qualified auity Sectio 401 qualified trusts 3 Loa Type Geeral Iformatio Choose oly oe type of loa. If you do ot check ay of the boxes, or if you choose more tha oe type of loa, your applicatio will be rejected. Istructios A. Check Loa Type 1 oly if you do ot have a existig loa from us ad are requestig oe. B. Loa Type 2 (multiple loa) allows you to take aother, separate loa from us. Multiple loas have separate five year due dates o which the miimum paymets are calculated. These miimum paymets are the added together for a total miimum paymet. That is why if you take aother loa uder this optio, you will have a higher miimum paymet tha if you refiace. However, the paymets for all loas will be combied so you oly have oe payroll deductio. C. Loa Type 3 (refiaced loa) allows you to add the ew loa amout to your existig loa balace ad refiace the etire amout as oe loa istead of takig aother, separate loa. Miimum repaymet amouts for refiaced loas are less tha multiple loas because we add o the amout you are curretly requestig to your existig loa. We the refiace the total amout for aother five years. Because of the icreased taxable amout for a refiaced loa, Federal withholdig ca sigificatly reduce the loa amout payable to you. 4 Loa Amout Geeral Iformatio There are various tax thresholds ad circumstaces that determie whe a loa is taxable ad what portio of a loa is taxable. Before choosig a taxable or o-taxable loa, you should call our automated iformatio lie to get specific iformatio regardig the amout you wat to borrow. The maximum o-taxable loa amout will be less for a refiaced loa (Loa Type 3) tha for a multiple loa (Loa Type 2), uless the etire amout of the refiaced loa is o-taxable. The taxable amout for a refiaced loa (Type 3) will always be more tha if you take a multiple loa (Loa Type 2), uless the etire amout of the refiaced loa is o-taxable. Whe choosig the Loa Repaymet Amout, you ca choose either to repay the miimum amout or a higher tha miimum amout each pay period. The miimum amout will be based o your payroll frequecy ad how much you must repay each payroll period based o a five-year repaymet pla. We will calculate what the miimum repaymet is if you choose this optio. If you select miimum paymet ad have multiple loas, your payroll deductio will equal the total of the miimum paymets for each loa. After your oldest loa is repaid, your payroll deductio will be reduced by the amout you had bee payig o that loa. Defiitio of a U.S. perso. For federal tax purposes, you are cosidered a U.S. perso if you are: - A idividual who is a U.S. citize or U.S. residet alie; - A partership, corporatio, compay, or associatio created or orgaized i the Uited States or uder the laws of the Uited States; - A estate (other tha a foreig estate); or - A domestic trust (as defied i Regulatios sectio ) If you are a U.S. Citize: This form will be used as a substitute for the W-9 tax form. You must complete this form i order to documet your U.S. citizeship status for tax withholdig ad iformatio reportig purposes. If you are a U.S. Citize ad you have bee otified by the IRS that you are curretly subject to backup withholdig because you have failed to report all iterest ad divideds o your tax retur, you must cross out item 2 i sectio 4C above. For real estate trasactios, item 2 does ot apply. For mortgage iterest paid, acquisitio or abadomet of secured property, cacellatio of debt, cotributios to a idividual retiremet arragemet (IRA), ad geerally, paymets other tha iterest ad divideds, you are ot required to sig the certificatio, but you must provide your correct TIN (Tax Idetificatio Number). If you are a No-Residet Alie: You must submit a W-8BEN tax form alog with your loa applicatio i order to documet your U.S. citizeship status for tax withholdig ad iformatio reportig purposes. You ca access ad prit this form from the IRS web site at: If you do ot submit a W-8BEN tax form with your loa applicatio, your applicatio will be rejected. Istructios A. Check oe box to tell us how much you wat to borrow. You have three choices: i. A loa for the maximum o-taxable amout we ca provide you by law (Box i) ii. A specific loa amout, up to the maximum amout available (Box ii). You must eter the amout you wat to borrow. iii. A loa for the maximum amout we ca provide you by law (a portio of this may be taxable) (Box iii) B. You may repay more tha the miimum amout, if you wish. Idicate the exact amout you wat to repay each pay period. If you wat to repay more tha the miimum amout ad are requestig Loa Type 2 (multiple loas), your payroll loa deductio will remai the same util all loas are paid, a ew loa is take, or you request i writig that your paymet be chaged to the miimum amout due. C. U.S. Citizeship Status - Check oe box to idicate whether you are a Citize, Residet Alie or No-Residet Alie. If you are a U.S. Citize or Residet Alie, your loa applicatio will be used as a substitute for the W-9 tax form. By completig ad sigig this form, you are agreeig to the certificatio statemets outlied i Sectio 4C. If you are a No-Residet Alie, you must submit a W-8BEN tax form with your loa applicatio. Loa applicatios received without a W-8BEN tax form will be rejected. D. Federal Tax Withheld Federal law requires us to withhold Federal tax at a rate of 10 percet of the taxable amout of the loa uless you elect ot to have this automatic withholdig apply. Federal withholdig ca sigificatly reduce the loa amout payable to you. 5 Payroll Iformatio Istructios A. Give us your employer s full ame so we ca otify them to take loa deductios. B. Provide your gross aual salary. C. To determie your loa repaymet amout, we eed to kow how ofte you are paid (check oe box oly). D. Tell us what your term of employmet is (check oe box oly). 6 Sigature We caot accept your loa applicatio uless it is siged. 7 Notary Public Ackowledgemet The applicatio must be otarized or it will be rejected.

5 RS 5025 (Rev. 9/17) Page 5 of 5 ALL TIER 1 AND TIER 2 LOANS ARE SUBJECT TO THE FOLLOWING: You must be i active service with the State or a participatig employer ad have credit for at least oe year of member service. Members o a leave of absece are ot cosidered to be i active service. If you are retirig, your loa applicatio must be received before your date of retiremet for it to be processed. Oly oe loa may be grated every 90 days. A loa may ot be grated for less tha $25. The maximum loa permitted uder law is 75 percet of the amout you have o deposit i your cotributio accout, less ay outstadig loa balace. If the requested loa amout exceeds the legal limit, your applicatio will be processed for the maximum amout permitted. The miimum repaymets must be i a amout sufficiet to repay the loa withi five years ad o less tha $3.00 if paid weekly, $5.00 if bi-weekly or semi-mothly, or $10.00 if mothly. Loa repaymets are i eve dollar amouts ad must be paid through payroll deductios. If you leave the payroll, or you are o a authorized leave of absece, please call us for iformatio o repayig your loa. If you do ot make paymets o your loa quarterly or complete paymet withi five years of the date the loa is issued, whichever comes first, your loa will be i default. At the time a default occurs, the etire amout due o your loa, mius ay previously taxed portio, must be reported to the Iteral Reveue Service (IRS) as a lump sum distributio from a qualified pla. However, the balace o a defaulted loa is still owed, ad iterest ad isurace charges cotiue to accrue util the balace is paid i full. If ay of your loas are i default, you will be uable to borrow from us i the future util the etire balace o all loas i default has bee repaid. If you are called to active military duty, special rules apply. Please cotact our Call Ceter. WARNING! If you retire or withdraw from the Retiremet System ad have a outstadig loa o the effective date of your retiremet or withdrawal, part or all of the loa balace may costitute taxable fuds which were credited to your accout ad, therefore, would be subject to Federal icome tax i the year i which you retire or withdraw. Sice this icome would ot be reportable util you retire or withdraw, iformatio regardig the amout will be furished to you at that time. Iterest is charged o loas at the rate of 5 percet per aum, based o the outstadig balace at the begiig of each moth. Loas are fully isured agaist the death of a member prior to retiremet. There is o isurace for the first 30 days. Premiums to cover the cost of this isurace are based o the amout of the loa ad your age, ad are charged agaist your cotributio balace at the ed of the year. Loa isurace does ot cover you if you become disabled or uemployed. IMPORTANT BENEFIT INFORMATION If you have a outstadig loa balace at the time of your retiremet, your beefit will be permaetly reduced. The followig table shows the approximate aual reductio i beefits for each $1,000 of loa outstadig at retiremet if you retire at various ages: EMPLOYEES RETIREMENT SYSTEM Service Retiremet Reductios Age at Retiremet Aual Reductio $77.77 $82.08 $84.27 $88.26 $97.35 POLICE & FIRE RETIREMENT SYSTEM Service Retiremet Reductios Age at Retiremet Aual Reductio $71.21 $73.56 $77.05 $81.95 $84.41 $88.84 IMPORTANT FEDERAL TAX INFORMATION Existig loas with a deferred compesatio or tax sheltered auity pla: If you have a existig loa from oe of these plas, both the curret loa balace ad the curret cotributio balace will be take ito accout whe calculatig the taxability of the loa from this system. 1. Loas over $50,000: No outstadig loa whe ew loa grated: Loas that exceed $50,000 must be reported to the IRS as a distributio from a qualified pla to the extet that the loa exceeds $50,000, less the highest outstadig loa balace i the past 12 moths. Refiaced Loa: Refiaced loas that cause the outstadig loa balace at the time the ew loa is grated (old balace) whe added to the replacemet loa (old balace plus the ew loa amout) to exceed $50,000, less the differece betwee the highest total outstadig balace durig the past year ad the old balace, must be reported to the IRS as a distributio from a qualified pla to the extet that the loa exceeds this amout. Multiple Loas: Loas that cause the loa accout (total of all outstadig loas plus the ew loa) to exceed $50,000, less the differece betwee the highest total outstadig balace durig the past year ad the total old balace (total of all outstadig loas prior to ew loa), must be reported to the IRS as a distributio from a qualified pla to the extet that the loa accout exceeds this amout. Ay portio of the distributio amout that caot be offset by your after-tax cotributio will be reported to the IRS as ordiary icome. 2. Loas uder $50,000: If there is o outstadig loa or a separate multiple loa is grated, ad the ew loa results i the total outstadig balace beig more tha the greater of (a) $10,000 or (b) 50 percet of the preset value of your accrued o-forfeitable beefit, the amout over that figure will be reported to the IRS as ordiary icome for the curret year. If you are ot vested, the preset value of your accrued o-forfeitable beefit is equal to your cotributio balace. If you are vested, the preset value of your accrued o-forfeitable beefit is a actuarially determied amout. For refiaced loas, the outstadig balace is the total of both the loa balace at the time the ew loa is grated ad the refiaced loa amout (which icludes the loa balace at the time the ew loa is grated). 3. If you go off the payroll, or your loa paymets stop prematurely, cotact the Call Ceter to make arragemets to repay your loa directly. If you do ot make paymets o your loa at least oce every three moths, or do ot complete repaymet withi five years from the date the loa is issued, your loa will default. Whe a loa defaults, the outstadig balace, mius ay previously taxed amout, must be reported to the IRS as ordiary icome. 4. If you are uder age 59½ at the time ay part of your loa becomes reportable, you may be subject to a additioal 10 percet pealty tax. The Federal Iteral Reveue Code imposes this pealty tax o amouts deemed to be a distributio prior to your actual retiremet.