Retired Beneficiary Verification Form - New Jersey Department Of The Treasury

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Mailing Address:
CB-0481-1011
STATE OF NEW JERSEY
Beneficiary Services
DEPARTMENT OF THE TREASURY
PO Box 295
DIVISION OF PENSIONS AND BENEFITS
Trenton, NJ 08625-0295
RETIRED BENEFICIARY VERIFICATION FORM
Instructions: Please complete this form and return to the Beneficiary Services Section at the address
shown above.
MEMBER INFORMATION:
Name: _____________________________________
SS #: _____________________________________
Pension Membership #: _______________________
County: ___________________________________
Address: __________________________________
__________________________________________
__________________________________________
BENEFICIARY INFORMATION:
Name: _____________________________________
Your Date of Birth: ___________________________
Address: ___________________________________
Daytime
Phone Number: ____________________________
__________________________________________
__________________________________________
Relationship to member (check one):
_ _ _ _ _ _ _ _ Spouse or Civil Union Partner
__________ Former Spouse or Civil Union Partner
__________ Other
Was member ever Divorced
Yes
No
(If Yes you must submit copies of the Divorce
Decree(s) with Property Settlement(s) and/or QDRO)
Certification Instructions
You must cross out item 2 below if you have been notified by the IRS that you are currently subject to backup withholding
because of underreporting interest or dividends on your tax return. The IRS does not require your consent to any provi-
sion of this document other than the certifications required to avoid backup withholding.
Tax Identification Number/Form W9 Certification
Under penalties of perjury, I certify that (1) the number provided below is my correct social security number or taxpayer
identification number, and (2) that I am not subject to backup withholding because (a) I have not been notified that I am
subject to backup withholding as a result of a failure to report interest or dividends, or (b) the Internal Revenue Service has
notified me that I am no longer subject to backup withholding.
By signing below, you are validating the above information is accurate and that you have read and acknowledge
receipt of disclosures regarding your settlement options, as well as the fraud warnings included as part of this for
(see reverse side for fraud warning information) .
_____________________________________
___________________________ __________________
Signature
Your Social Security Number or
Date
Taxpayer Identification Number

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