New York State and Local Retirement System (NYSLRS) Membership Withdrawal Application (RS 5014)

State employee applies to withdraw membership and contributions from NYSLRS pension.

Download the Form

NYSLRS Withdrawal Application (RS 5014)
Mobile Users

For the best experience in completing this form use a non-mobile device.

Using Firefox with PDF forms?

Make Adobe Acrobat the reader.

Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

New York State and Local Retirement System
110 State Street
Albany, New York 12244-0001

Need Help Completing the Form?

Contact NYSLRS

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: November 2012

Owner: Office of the New York State Comptroller, New York State and Local Retirement System