Form Cd-0363-0605 Employers' Certification: Death Claim
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2CD-0363-0605
STATE OF NEW JERSEY
Department of the Treasury - Division of Pensions and Benefits
PO Box 295, Trenton, NJ 08625-0295
EMPLOYERS’ CERTIFICATION: DEATH CLAIM
(Please see reverse side for instructions)
Retirement System (Check One):
PERS
TPAF
PFRS
SPRS
ABP
1. Name of Deceased ____________________________
2. Membership No. ______________________________
3. Date Employed _______________________________
4. Social Security Number _________________________
5. Last Day of Active Service ______________________
6. Date of Death ________________________________
7. Was death due to an accident in the course of employment?
Yes
No
8. Was member on an official leave of absence with or without pay?
Yes
No — If yes, you must give date
granted, reason, and support documentation.
L/A With Pay _______________
L/A Without Pay _______________
Other ____________________
(Date) From - To
(Date) From - To
(Date) From - To
Reason for Leave _______________________________________________________________________________
Please be certain to attach a resolution, board minutes, or statement from employer for an employee
who was on a leave of absence without pay at the time of death. This claim cannot be processed
unless official documentation from the employer is included with this certification.
9. Base salaries during the last 6 months of creditable service prior to date of death. For those employees paid through
the State Centralized Payroll Unit, see instructions on the back.
Base Salary
Back
Supplemental
Arrears
Subject to
Deductions
Annuity
Total
and/or
Contributions
Pension
Loan
Amount
Purchases
Deduction
Month - Year
This Quarter
Contribution
Repayment
Amount
1.
2.
3.
4.
5.
6.
10. Annual salaries and effective dates of wages in last year of service (see instructions for example):
$ ______________
______________
$ ______________
______________
$ ______________
______________
Salary
Date
Salary
Date
Salary
Date
11. Last Deduction Made for Retirement System: Payroll Period
___________________________________________________
Amount of Pension Deduction
_________________________
Salary
_________________________
$
$
12. If Contributory Insurance in force, give Payroll Period from which last deduction was made (PERS and TPAF only)
_____
______________________
_______________________________________________________
__________________________
Date
Signature of Certifying Officer
Phone Number
_______________________________________________________________________
__________________________________
Employing Agency
County
THIS CLAIM CANNOT BE PROCESSED UNLESS ALL ITEMS ARE COMPLETED
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