Date: October 5, 2017

Bulletin Number: CU-602

Subject Revised Form for TIAA Eligible Employees

Purpose To inform agencies of the changes to the TIAA Action Request (AC-1767) form.

Affected Employees

Employees who have prior service credit in an employer sponsored optional retirement plan.

Background The TIAA Action Request (AC-1767) form is used to request a waiver of the suspense period or an election date change for an employee that has prior service with a qualified employer sponsored retirement plan.  This form has been updated to include additional information required for OSC’s audit and approval.

Effective Date


Agency Actions Agencies should destroy all previous TIAA Action Request (AC-1767) forms.  The new TIAA Action Request AC-1767 (Rev.07/17) form is available on the State Payroll Services Forms Page.

The new form requires agencies to provide additional information and certify that they have verified all prior service with the retirement plan providers.  The fields below have been added and should be completed by the Agency.

  • Last 4 of SSN
  • Hire Date
  • Employee’s Signature Date (Date of Employee Request)
  • SUNY/CUNY Affiliated Community College (Y/N)
    • Break In Service (Y/N)
      • Termination Date (Beginning of Break in Service)
      • Rehire Date (Ending of Break in Service)
  • A Portion of the Employees Suspense Period is Being Waived (Y/N)
  • Approved Election Date
  • Verification of All Prior Service With Appropriate Retirement Plan Provider(s)

OSC Actions OSC now requires additional information from state agencies in order to process TIAA Action Requests.  Once reviewed and approved, OSC will update all necessary dates in PayServ and waive the suspense period when necessary. AC-1767 forms submitted without this additional information will be returned to the agency and will not be processed.

Questions Questions regarding this bulletin may be directed to the Payroll Retirement mailbox.