New York State Troopers PBA Supplemental Fund Application and Agreement

*Next of kin information is kept for the sole purpose of contacting a Plan Participant if necessary.

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 for at least 12 months, 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 a timely application must be made by the December 31 of the calendar year in which I become eligible for the Plan.

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 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.

*Please note that after submitting your application there will be a screen that says "Thank you! Your submission has been received."  If you do NOT see this screen please email pbafund@nystpba.org to verify it was received.  You will not receive a separate email verification after submitting.