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Complete this form in its entirety sign it have it notarized and send it to NYCERS at the mailing address above. NYCERS USE ONLY F625 Mail completed form to 30-30 47th Avenue 10th Fl Long Island City NY 11101 Application for Disability Retirement 22-Year Plan Members This application is for 22-Year Plan members who are applying for Disability Retirement. 1. You must have joined NYCERS on or after April 1 2012. 2. You have at least five years of service credit. Withdrawal of Application...

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