Enrollment Application Form - New Jersey Department Of The Treasury

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ABP-10-0001-1215
STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY
FOR DIVISION USE ONLY
DIVISION OF PENSIONS AND BENEFITS
PO BOX 295, TRENTON, NJ 08625-0295
ALTERNATE BENEFIT PROGRAM
ENROLLMENT APPLICATION
(Please do not complete this form until you read the reverse side.)
PART I
MEMBER INFORMATION
Please print clearly or type.
1. Name
Mr.
Mrs.
Miss
Ms.___________________________________________________________________
FIRST
MIDDLE
LAST
2. Date of Birth _________________________________________
MONTH
DAY
YEAR
3. Address ________________________________________________________________________________________________
STREET
_________________________________________________________________________________________________________________________________________________________
CITY
STATE
ZIP CODE
4. Daytime Telephone No (______) _____________________ 5. Social Security Number ______________________________
6. Have you ever been a member of a New Jersey Administered Pension Fund?
Yes
No
If yes, check fund and indicate membership number:
ABP
PERS
TPAF
PFRS
SPRS
Membership number: ____________________
Are you retired from this Pension Fund?
Yes
No
7. Are you eligible for immediate vesting in the ABP? (eligibility criteria on reverse side)
Yes
No
If yes, identify how you qualify. ______________________________________________________________
_____________________________________________________________ ____________________________________________
SIGNATURE OF APPLICANT
DATE
CASH DISTRIBUTION (VESTED MEMBERS ONLY)
PART II
A member of the Alternate Benefit Program (ABP) becomes eligible to commence distributions at any age upon severance from employ-
ment or retirement. Members may receive benefits in the form of an annuity or cash distribution. Annuity benefits will be calculated by
the Designated Service Provider (DSP) based upon the account accumulation, life expectancy, and the distribution option selected. Cash
distributions to members under the age of 55 are limited to their employee contributions and accumulations. The remaining employer
contributions and earnings are available for distribution upon attaining age 55. Participation in the Alternate Benefit Program shall ter-
minate and the individual shall be considered retired once he or she has elected to receive a cash distribution of the value of his or her
accounts in a direct payout as a cash distribution, a rollover, or an annuity (or a combination of these distributions). The member is con-
sidered retired and is not eligible to enroll in any New Jersey State-administered retirement system, nor are they eligible to reenroll in
the Alternate Benefit Program. I hereby acknowledge that I have been counseled regarding my election to withdraw funds from my
mandatory 401(a) account.
PART III
CERTIFICATION OF EMPLOYING AGENCY
To be completed by the employer.
Title of Position _______________________________ Employed:
10
12 months Appointment Date _____/_____/______
Employing Institution ___________________________ Loc. # ____________________ Annual Base Salary $ ________________
Full Time Employee
Yes
No
Academic Position
Yes
No
Bachelor's Degree
Yes
No
Administrative Position
Yes
No
Immediately Vested
Yes
No
Adjunct/Part-time Faculty
Yes
No
I certify that this employee and position meets the eligibility criteria for the retirement system as provided by law. I acknowledge that I
am subject to penalty for falsifying or permitting to be falsified any record, application, form, or report of the retirement system in an
attempt to defraud the system pursuant to N.J.S.A. 43:3C-15. (Two Signatures Required)
_______________________________________________
__________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
SIGNATURE OF CERTIFYING OFFICER
TITLE
DATE
_______________________________________________
__________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
SIGNATURE OF CERTIFYING OFFICER’S SUPERVISOR
TITLE
DATE

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