Form Cd-0532-0616q Application For Last Check Benefit

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CD-0532-0616q
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY — DIVISION OF PENSIONS AND BENEFITS
BENEFICIARY SERVICES
PO BOX 295
TRENTON, NJ 08625-0295
APPLICATION FOR LAST CHECK BENEFIT
Member’s Name ______________________________________
Retirement No. ____________________
Please Print
State statutes provide that a pension annuity, retirement allowance, or pension adjustment is payable for the
entire month in which the retiree or beneficiary dies. As the designated beneficiary you are entitled to this check,
which is dated for the first of the month following the month in which the member passed away. If this check has
already been cashed you may waive it to the member’s estate. However, as the designated beneficiary, if you
choose to have this benefit payable to you, the Division of Pensions and Benefits will not process a replacement
check to you until our check is returned.
Select one of the choices in Part One, complete Part Two, and sign this form. Return the completed form to
the address shown above.
PART ONE – Choose one only
1.
The last pension check was negotiated. I hereby waive my right to the check since it was
deposited to the account of the person named above.
2.
The last pension check was deposited directly into the member’s account. I authorize the
Division of Pensions and Benefits to request that the bank return the direct deposit. Upon
receipt, please issue the last check benefit to me.
3.
I am enclosing the uncashed pension check or the check has been recently returned to the
Division.
4.
Since the last check benefit was mailed directly to the member, I authorize the Division of
Pensions and Benefits to take the necessary steps to recover these funds. Once the Division
has recovered the funds, please issue the last check benefit to me.
PART TWO
Your Name ________________________________________
SS # _____________________________
Please Print
Address ________________________________________________________________________________
Street
_______________________________________________________________________________________
City
State
ZIP Code
Daytime Phone No.: (_____) ___________________________
Signature _________________________________________
Date _____________________________

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