What Is This Form For?
To decline membership in the NYS Employee Retirement System (ERS). You can only use this form is you are a temporary, part-time, or provisional employee.
Download the Form:
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Declination of Membership in the New York State Employees' Retirement System (BSC-B4)
Use this form to decline membership in the NYS Employees' Retirement System. This form can only be used by temporary, part-time, or provisional employees.
Download
Is This Form Mandatory?
No.
When to Submit
Return this form within 30 days of your start date.
How to Complete This Form
This form is fillable.
- Complete "Employee Name," "Agency Code," and "Employee ID."
- Indicate your "Appointment Type."
- Print out the form.
- Sign the form.
- Send your original, signed form to the BSC.
Where to Submit This Form
Email:
Fax:
518-457-1879
Mail:
BSC Benefits Administration
W. Averell Harriman State Office Campus
1220 Washington Avenue
Building 5, Floor 4
Albany, NY 12226-1900
Contact the BSC Benefits Team
Still have questions? Try the BSC Help Center where you can send a question to our support team or search a database of FAQs.
Human Resources, BSC Records Management
Building 5, Floor 4
W. Averell Harriman State Office Campus
1220 Washington Ave
Albany, NY 12226-1900