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NYCERS

RETIREMENT AND BENEFITS

In the Matter of the Estate of: First Name Last Name Last Place of Residence Place of Birth

NEW YORK CITY EMPLOYEES' RETIREMENT SYSTEM

Mail Only: Customer Service Center: 335 Adams Street, 340 Jay Street, Suite 2300 Mezzanine Level Brooklyn, NY 11201-3724 Brooklyn, NY 11201-3724 Tel: (347) 643-3000 Executive Director: Diane D'Alessandro

For Office Use Only

Benefit Claimed Under §1310 of the Surrogate's Court Procedure Act for Funeral Expenses

Clock-in-Date

Middle Initial Membership/ Pension # Date of Birth Date of Death

M M

M

M

/ /

D

D

/ /

Y

Y

Y

Y

D

D

Y

Y

Y

Y

A copy of the death certificate must be submitted herewith. I, I reside at Address City State Apt. Number Zip Code , being duly sworn, depose and say that:

I make this claim as I have paid the funeral expenses of the above captioned decedent, at the request of the surviving spouse or a relative. I have attached hereto the bill for the funeral expenses. No Fiduciary, Executor or Administrator has qualified or been appointed. The above named decedent was not survived by a spouse or minor child. This payment and all other payments made under §1310 of the Surrogates Court Procedure Act, known to me, after diligent inquiry, do not in the aggregate exceed $5,000. More than six months have elapsed since the death of the decedent. I am entitled to the payment herein and do induce the New York City Employees' Retirement System (NYCERS) to pay me the amount due, knowing full well that NYCERS will rely on the truth of the statements herein contained in making such payment. I agree for myself and my executors, administrators or assigns to hold NYCERS forever harmless and to indemnify it from any and all liability, loss, damage, claims, suits, costs or expenses whatsoever which may arise directly or indirectly from making such payment.

In use beginning September 2007

Claim Form for Funeral Exp

Sign this form and have it notarized, Page 2

Form #362

Page 1 of 2

NYCERS

RETIREMENT AND BENEFITS Membership/ Pension #

Signature of Claimant

NEW YORK CITY EMPLOYEES' RETIREMENT SYSTEM

Mail Only: Customer Service Center: 335 Adams Street, 340 Jay Street, Suite 2300 Mezzanine Level Brooklyn, NY 11201-3724 Brooklyn, NY 11201-3724 Tel: (347) 643-3000 Executive Director: Diane D'Alessandro

For Office Use Only

Clock-in-Date

Member/Pensioners' Last 4 Digits of Social Security #

Social Security #

This form must be acknowledged before a Notary Public or Commissioner of Deeds State of On this County of day of

20

, personally appeared before me the above named,

to me known, and known to me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she executed the same, and that the statements contained therein are true. If you have an official seal, affix it. Signature of Notary Public or Commissioner of Deeds Official Title Expiration Date of Commission

In use beginning September 2007

Claim Form for Funeral Exp

Sign this form and have it notarized, THIS PAGE

Form #362

Page 2 of 2

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