New York State Troopers PBA Supplemental Fund Application and Agreement

New York State Troopers PBA Supplemental Fund Application and Agreement
APPLICANT INFORMATION
**Please DO NOT use punctuation anywhere on the form.

i.e. John D Doe Jr or 123 Example Rd Albany New York 12207

Additionally, kindly ensure ALL information is accurate before submitting the form as any errors may lead to delays in processing or possible rejection of your application.
Name*
First Name
MI
Last Name
Suffix (i.e. Jr, Sr, II)
Address*
Street Address
Street Address Line 2
City
Zip Code
Phone Number (home)
Please enter a valid phone number.
Phone Number (cell)*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Please verify DOB is correct before continuing
Email*

Confirmation EmailVerify Email by entering it again
Next of Kin Name*
Relationship*
Next of Kin Address*

Street Address

Street Address Line 2

CityState

Zip Code
Next of Kin Email*
example@example.com
Next of Kin Phone Number*
Please enter a valid phone number.
*Next of kin information is kept for the sole purpose of contacting a Plan Participant if necessary.
EMPLOYMENT INFORMATION
Date of Hire (EOD)*

MonthDayYear
Date
Date of Separation from Service*

MonthDayYear
Date
Unit Upon Retirement*

Troopers UnitSupervisors UnitNYSPIAManagement ConfidentialOther
Troop Upon Retirement*
Type of Retirement*

Service RetirementDisability/Accidental RetirementOther
NYSTPBA Member In Good Standing Upon Retirement?*

YesNo
I hereby certify that the information above is true and accurate. I understand and agree that providing false, inaccurate or misleading information could result in a forfeiture of my supplemental benefit, to the extent that I am entitled to a benefit under the Plan.

I understand that the purpose of the Plan is to provide Qualified Members, who have been separated from service on or before December 31, 2023, with an annual grant of benefits after the member has a qualifying separation from service from the Division of State Police, as set forth in the NYSTPBA Supplemental Fund Summary Plan Description and as determined by the NYSTPBA Supplemental Fund Board of Trustees.

I understand that the Plan does not provide any spousal, death or survivor benefits and that my next of kin is required to notify the NYSTPBA of my death as soon as practicable but no longer than 30 days after this benefit ceases. I understand that Plan benefits are subject to claw-back.

I understand that submitting the above application for the Plan does not guarantee eligibility or payment.

I understand that a timely application must be made by September 30 of the calendar year in which I become eligible for the Plan.

I understand that any payment of Plan benefits to a Participant is taxable to the Participant in the Determination Year which the payment is made. The Board is authorized to withhold from any payment of Plan benefits to a Participant any federal, state or local income or payroll taxes required by law.

Any questions can be emailed to pbafund@nystpba.org.

ALL REQUESTED INFORMATION MUST BE COMPLETED OR APPLICATION WILL NOT BE PROCESSED.
I acknowledge that I have read and understand the terms detailed above:*

I agreeI do not agree
*The collection of personal data by the NYSTPBA is conducted solely for the purpose of verifying application information. For additional information regarding the use and protection of your data, please consult the applicable terms and conditions.
Signature*

Clear
Date*

MonthDayYear
Date
**Please note: After submitting your application, a confirmation screen will appear with the message "Thank you! Your submission has been received." Additionally, you will receive a separate email verification from noreply@jotform.com. If you do not receive this verification email, please contact us at pbafund@nystpba.org.
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New York State Troopers PBA Supplemental Fund Application and Agreement

APPLICANT INFORMATION

EMPLOYMENT INFORMATION