Ep-0233-0415 Employment Verification Form
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1Letter Dated:
EP-0233-0415
State of New Jersey — Department of the Treasury
____/____/____
Division of Pensions and Benefits, PO Box 295, Trenton, NJ 08625-0295 - (609) 292-7524 / TDD# (609) 292-6683
EMPLOYMENT VERIFICATION FORM
THIS SECTION TO BE COMPLETED BY MEMBER:Check the Pension System to which you now belong:
o Public Employee’s Retirement System (PERS)
o Teachers Pension and Annuity Fund (TPAF)
o Police and Firemen’s Retirement System (PFRS)
Name : _____________________________________________________________________________
Maiden and/or Former Name(s) (if applicable): ________________________
First
M.I.
Last
Address: _______________________________________________________________________________________________________________
Street
City
State
Zip Code
Date of Birth: _______________________
S ocial Security Number: ___________________________________
Membership Nmber: _______________________________
(Month/Day/Year)
THIS SECTION TO BE COMPLETED BY EMPLOYER. NOTE: Please refer to attached instructions for proper form completion.
The person named on this form is an active member of a retirement system administered by the New Jersey Division of Pensions and Benefits and wishes
to purchase additional service credit. To assist this member in establishing additional service credit, please provide the required information below.
1. NAME OF EMPLOYER: ___________________________________________________
4. Date of
5. Employment Dates CERTIFY EACH YEAR
6. Base Salary
7. Substitute
8. Hours Worked
Monthly o
2. Official Payroll Title
3. Date of Hire
Permanent
SEPARATELY – (BOARDS OF EDUCATION
Service
o
Appointment
MUST USE SCHOOL YEARS)
(# of days)
Annual
o F/T o P/T
____/____/____
____/____/____
From: ____/____/____
To: ____/____/____
o F/T o P/T
____/____/____
____/____/____
From: ____/____/____
To: ____/____/____
o F/T o P/T
____/____/____
____/____/____
From: ____/____/____
To: ____/____/____
o F/T o P/T
____/____/____
____/____/____
From: ____/____/____
To: ____/____/____
9. (BOARD OF EDUCATION CERTIFYING OFFICERS ONLY): Please indicate the number of months in each regular school year:_____________
(maternity and child care are two separate types of leave of absence)
12. Medical documentation
10. Dates for Leaves of Absence
11. Reason for Leaves of Absence DO NOT LIST FMLA– SEE INSTRUCTIONS FOR #11 & #12
on file
o Yes o No
From: ____/____/____
To: ____/____/____
o Yes o No
From: ____/____/____
To: ____/____/____
o Yes o No
From: ____/____/____
To: ____/____/____
13. Were the positions listed in Item 2 covered by Social Security? o Yes
o No
o Public
o Private
15. Is the employer a public or private entity?
14. Was this employee a member of a pension fund while in the position listed in
I herby certify that the answers and information given are based upon available authentic
o Yes
o No
Item 2?
public records and that they are true and correct to the best of my knowledge and belief.
Employer’s
If yes, is this employee receiving or entitled to receive a retirement benefit?
o Yes
o No
Certifying Signature:
___________________________________________________
Please give the name and address of the fund’s central office.
Title: __________________________________________________________________
_______________________________________________________________________
Date: __________________________________________________________________
_______________________________________________________________________
g
Phone#: ________________________________________________________________
_______________________________________________________________________
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